Provider Demographics
NPI:1912216532
Name:PINELAKE PHYSICIAN PRACTICE LLC
Entity Type:Organization
Organization Name:PINELAKE PHYSICIAN PRACTICE LLC
Other - Org Name:JACKSON PURCHASE FAMILY AND SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DENIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-934-1454
Mailing Address - Street 1:1029 MEDICAL CENTER CIR
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-1189
Mailing Address - Country:US
Mailing Address - Phone:270-251-4547
Mailing Address - Fax:270-251-4546
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:270-251-4085
Practice Address - Fax:270-251-4086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty