Provider Demographics
NPI:1700970613
Name:PINEVILLE PRIMARY CARE, PSC
Entity Type:Organization
Organization Name:PINEVILLE PRIMARY CARE, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEVAPIRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JAISHANKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-337-7157
Mailing Address - Street 1:332 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40977-1422
Mailing Address - Country:US
Mailing Address - Phone:606-337-7157
Mailing Address - Fax:
Practice Address - Street 1:850 RIVERVIEW RD
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:PINEVILLE
Practice Address - State:KY
Practice Address - Zip Code:40977-1430
Practice Address - Country:US
Practice Address - Phone:606-337-7157
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN32079207R00000X
TN33451208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
64343510Medicare ID - Type Unspecified