1033167515 NPI number — CUMBERLAND ORTHOPAEDICS AND SPORTS MEDICINE, PLLC

Table of content: (NPI 1033167515)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033167515 NPI number — CUMBERLAND ORTHOPAEDICS AND SPORTS MEDICINE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CUMBERLAND ORTHOPAEDICS AND SPORTS MEDICINE, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033167515
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
160 LONDON MOUNTAIN VIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONDON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40741-6601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-864-0770
Provider Business Mailing Address Fax Number:
606-864-1461

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
160 LONDON MOUNTAIN VIEW DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONDON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40741-6601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-864-0770
Provider Business Practice Location Address Fax Number:
606-864-1461
Provider Enumeration Date:
05/05/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PAGE'
Authorized Official First Name:
JEAN
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
PRESIDENT OWNER
Authorized Official Telephone Number:
606-864-0770

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: 00308 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 65933327 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: CB6337 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 164304800 . This is a "WORKERS COMPENSATION" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7890447100 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 95901328 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".