Healthcare Provider Details

I. General information

NPI: 1861563439
Provider Name (Legal Business Name): PINELAKE PHYSICIAN PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/13/2023
Certification Date: 07/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 S 7TH ST
HICKMAN KY
42050-1841
US

IV. Provider business mailing address

330 SEVEN SPRINGS WAY ATTEN PROVIDER ENROLLMENT
BRENTWOOD TN
37027-5098
US

V. Phone/Fax

Practice location:
  • Phone:
  • Fax:
Mailing address:
  • Phone: 615-920-7000
  • Fax: 615-920-8775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 14
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State
# 15
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MONICA BOWMAN
Title or Position: PRESIDENT
Credential:
Phone: 615-920-7000