Basic Information
| Provider Information | |||||||||
| NPI: | 1336314442 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PINELAKE PHYSICIAN PRACTICES LLC | ||||||||
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| OtherOrganizationName: | JACKSON PURCHASE NEPHROLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1029 MEDICAL CENTER CIR | ||||||||
| Address2: | SUITE 200 A | ||||||||
| City: | MAYFIELD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420661189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702514545 | ||||||||
| FaxNumber: | 2702514546 | ||||||||
| Practice Location | |||||||||
| Address1: | 1029 MEDICAL CENTER CIR | ||||||||
| Address2: | SUITE 200 A | ||||||||
| City: | MAYFIELD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420661189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702514545 | ||||||||
| FaxNumber: | 2702514546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2008 | ||||||||
| LastUpdateDate: | 04/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | WEISS | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIVISION PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6153758500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.