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General NPI Number Information
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NPI Number | 1295960532
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Entity Type | Organization
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Legal Business Name | PINELAKE PHYSICIAN PRACTICE, LLC
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Dates
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Enumeration Date | 05/15/2009
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Last Update Date | 05/08/2023
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Provider Practice Location Address
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Address Line | 1111 MEDICAL CENTER CIR
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City | MAYFIELD
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State | KY
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Zip | 42066-1194
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Country | US
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Telephone | 270-251-4543
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Fax | 270-251-4544
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Provider Business Mailing Address
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Address Line | 330 SEVEN SPRINGS WAY ATTEN: PROVIDER ENROLLMENT
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City | BRENTWOOD
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State | TN
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Zip | 37027-5098
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Country | US
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Telephone | 615-920-7192
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Fax | 615-920-8775
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Authorized Official
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Title or Position | SR. DIRECTOR
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Name | MONICA BOWMAN
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Credential |
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Telephone | 615-920-7000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State |
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