Basic Information
| Provider Information | |||||||||
| NPI: | 1295960532 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PINELAKE PHYSICIAN PRACTICE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 SEVEN SPRINGS WAY | ||||||||
| Address2: | ATTEN: PROVIDER ENROLLMENT | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159207192 | ||||||||
| FaxNumber: | 6159208775 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 MEDICAL CENTER CIR | ||||||||
| Address2: | |||||||||
| City: | MAYFIELD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420661194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702514543 | ||||||||
| FaxNumber: | 2702514544 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2009 | ||||||||
| LastUpdateDate: | 05/14/2019 | ||||||||
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| AuthorizedOfficialLastName: | LEBLEU | ||||||||
| AuthorizedOfficialFirstName: | SHARLEE | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR. DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6159207192 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 7100335050 | 05 | KY | MEDICAID | 000000618910 | 01 | KY | ANTHEM | OTHER |