Provider Demographics
NPI:1912720665
Name:LAKE CUMBERLAND RHEUMATOLOGY PLLC
Entity type:Organization
Organization Name:LAKE CUMBERLAND RHEUMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:502-495-3665
Mailing Address - Street 1:101 PROSPEROUS PL STE 350
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-1891
Mailing Address - Country:US
Mailing Address - Phone:859-654-0160
Mailing Address - Fax:859-712-9273
Practice Address - Street 1:101 PROSPEROUS PL STE 350
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1891
Practice Address - Country:US
Practice Address - Phone:859-654-0160
Practice Address - Fax:859-712-9273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-01
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Single Specialty