Provider Demographics
NPI:1033167515
Name:CUMBERLAND ORTHOPAEDICS AND SPORTS MEDICINE, PLLC
Entity type:Organization
Organization Name:CUMBERLAND ORTHOPAEDICS AND SPORTS MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:PAGE'
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-864-0770
Mailing Address - Street 1:160 LONDON MOUNTAIN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-6601
Mailing Address - Country:US
Mailing Address - Phone:606-864-0770
Mailing Address - Fax:606-864-1461
Practice Address - Street 1:160 LONDON MOUNTAIN VIEW DR
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-6601
Practice Address - Country:US
Practice Address - Phone:606-864-0770
Practice Address - Fax:606-864-1461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 363L00000X, 207X00000X
KY00308213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65933327Medicaid
CB6337OtherRAILROAD MEDICARE
164304800OtherWORKERS COMPENSATION
KY7890447100Medicaid
KY95901328Medicaid
CB6337OtherRAILROAD MEDICARE