Healthcare Provider Details

I. General information

NPI: 1891892741
Provider Name (Legal Business Name): PINELAKE REGIONAL HOSPITAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1099 MEDICAL CENTER CIR
MAYFIELD KY
42066-1159
US

IV. Provider business mailing address

330 SEVEN SPRINGS WAY
BRENTWOOD TN
37027-5098
US

V. Phone/Fax

Practice location:
  • Phone: 270-251-4100
  • Fax: 270-251-4507
Mailing address:
  • Phone: 615-920-7000
  • Fax: 615-920-8913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number100143
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code282NR1301X
TaxonomyRural Acute Care Hospital
License Number100143
License Number StateKY

VIII. Authorized Official

Name: TERRANCE DILLON
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 502-596-7220