Provider Demographics
NPI:1336314442
Name:PINELAKE PHYSICIAN PRACTICES LLC
Entity Type:Organization
Organization Name:PINELAKE PHYSICIAN PRACTICES LLC
Other - Org Name:JACKSON PURCHASE NEPHROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIVISION PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WEISS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-375-8500
Mailing Address - Street 1:1029 MEDICAL CENTER CIR
Mailing Address - Street 2:SUITE 200 A
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-1189
Mailing Address - Country:US
Mailing Address - Phone:270-251-4545
Mailing Address - Fax:270-251-4546
Practice Address - Street 1:1029 MEDICAL CENTER CIR
Practice Address - Street 2:SUITE 200 A
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-1189
Practice Address - Country:US
Practice Address - Phone:270-251-4545
Practice Address - Fax:270-251-4546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty