Provider Demographics
NPI:1295960532
Name:PINELAKE PHYSICIAN PRACTICE, LLC
Entity type:Organization
Organization Name:PINELAKE PHYSICIAN PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-920-7000
Mailing Address - Street 1:330 SEVEN SPRINGS WAY
Mailing Address - Street 2:ATTEN: PROVIDER ENROLLMENT
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5098
Mailing Address - Country:US
Mailing Address - Phone:615-920-7192
Mailing Address - Fax:615-920-8775
Practice Address - Street 1:1111 MEDICAL CENTER CIR
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-1194
Practice Address - Country:US
Practice Address - Phone:270-251-4543
Practice Address - Fax:270-251-4544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-15
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000618910OtherANTHEM
KY7100335050Medicaid