Provider Demographics
NPI:1063551422
Name:CUMBERLAND CONVENIENT CARE MEDICAL CENTER
Entity type:Organization
Organization Name:CUMBERLAND CONVENIENT CARE MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:T
Authorized Official - Last Name:LLOYD-JONES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-462-9909
Mailing Address - Street 1:10 W BOYD AVE
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-1401
Mailing Address - Country:US
Mailing Address - Phone:317-462-9909
Mailing Address - Fax:317-462-5313
Practice Address - Street 1:10 W BOYD AVE
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-1401
Practice Address - Country:US
Practice Address - Phone:317-462-9909
Practice Address - Fax:317-462-5313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000100A363L00000X
IN71002243A363L00000X
IN01028055A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INB28878Medicare UPIN
IN797980AMedicare PIN