Basic Information
| Provider Information | |||||||||
| NPI: | 1912512724 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CUMBERLAND FOOT AND ANKLE CENTERS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 TRADEPARK DR STE B | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425033428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066792773 | ||||||||
| FaxNumber: | 6066794626 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 MEMORIAL DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421342752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708463338 | ||||||||
| FaxNumber: | 2708463318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2020 | ||||||||
| LastUpdateDate: | 03/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | MOORE | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/PODIATRIST | ||||||||
| AuthorizedOfficialTelephone: | 6066792773 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
| NPICertificationDate: | 03/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7100207030 | 05 | KY | MEDICAID | 7100234690 | 05 | KY | MEDICAID |