Lily Creek Medical Group, PSC

Primary specialty

Internal Medicine PhysicianTaxonomy code 207R00000X

Legal business name

LILY CREEK MEDICAL GROUP, PSC

Practice address

92 Joe T Petty Dr
Russell Springs, KY 42642-8543

Phone

(270) 866-8881

Fax

(270) 866-8849

NPI assigned

Jan 15, 2007

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Robert L. Bertram, D.O.

Title

President

Phone

(270) 866-8881

Specialties & licenses 3

Addresses

Other identifiers 3

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1168819200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1225324800000",
    "number": "1205987542",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 5007",
            "city": "FRANKFORT",
            "state": "KY",
            "postal_code": "406025007",
            "telephone_number": "502-226-3858",
            "fax_number": "502-223-9829"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "92 JOE T PETTY DR",
            "city": "RUSSELL SPRINGS",
            "state": "KY",
            "postal_code": "426428543",
            "telephone_number": "270-866-8881",
            "fax_number": "270-866-8849"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LILY CREEK MEDICAL GROUP, PSC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-15",
        "last_updated": "2008-10-30",
        "status": "A",
        "authorized_official_last_name": "BERTRAM",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_middle_name": "L.",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "270-866-8881",
        "authorized_official_credential": "D.O."
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM",
            "identifier": "000000064586",
            "state": "KY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLACK LUNG",
            "identifier": "608475500",
            "state": "KY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "65932386",
            "state": "KY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Internal Medicine Physician in Russell Springs, KY
• Providers in Russell Springs, KY by specialty
• Internal Medicine Physician in Kentucky

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 30, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.