Provider Demographics
NPI:1962718155
Name:CUMBERLAND FOOT AND ANKLE CENTER
Entity type:Organization
Organization Name:CUMBERLAND FOOT AND ANKLE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:606-679-2773
Mailing Address - Street 1:117 TRADEPARK DR
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-3428
Mailing Address - Country:US
Mailing Address - Phone:606-679-2773
Mailing Address - Fax:606-679-4626
Practice Address - Street 1:1007 CUMBERLAND FALLS HWY
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-2714
Practice Address - Country:US
Practice Address - Phone:606-258-8637
Practice Address - Fax:606-523-4368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-25
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90005091Medicaid
KY90005091Medicaid