Basic Information
| Provider Information | |||||||||
| NPI: | 1972738839 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PINELAKE PHYSICIAN PRACTICE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MAYFIELD GENERAL SURGERY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 MEDICAL CENTER CIR | ||||||||
| Address2: | |||||||||
| City: | MAYFIELD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420661194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702514547 | ||||||||
| FaxNumber: | 2702514546 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 MEDICAL CENTER CIR | ||||||||
| Address2: | |||||||||
| City: | MAYFIELD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420661194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702514547 | ||||||||
| FaxNumber: | 2702514546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2009 | ||||||||
| LastUpdateDate: | 10/25/2010 | ||||||||
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| AuthorizedOfficialLastName: | WEISS | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6153728500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.