Healthcare Provider Details

I. General information

NPI: 1942535281
Provider Name (Legal Business Name): PINELAKE PHYSICIAN PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2009
Last Update Date: 11/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 MEDICAL CENTER CIR
MAYFIELD KY
42066-1194
US

IV. Provider business mailing address

1029 MEDICAL CENTER CIR
MAYFIELD KY
42066-1189
US

V. Phone/Fax

Practice location:
  • Phone: 270-251-4070
  • Fax: 270-251-4074
Mailing address:
  • Phone: 270-251-4547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY VAUGHN
Title or Position: VICE PRESIDENT
Credential:
Phone: 615-565-1513