# PINELAKE PHYSICIAN PRACTICE LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Jackson Purchase ENT & Aesthetic Surgery
- **Organization subpart:** No

## Provider details

- **NPI number:** 1255650479
- **Authorized official:** TIMOTHY D VAUGHN (VICE PRESIDENT)
- **Authorized official phone:** (615) 372-8500

## Contact information

- **Practice address:** 1111 MEDICAL CENTER CIR, MAYFIELD, KY 42066-1194
- **Practice address phone:** (270) 251-4080
- **Practice address fax:** (270) 251-4081
- **Mailing address:** 1029 MEDICAL CENTER CIR, MAYFIELD, KY 42066-1189
- **Mailing address phone:** (270) 251-4080
- **Mailing address fax:** (270) 251-4081

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207YX0905X | Otolaryngology/Facial Plastic Surgery Physician | — | NULL | Yes |
| 207YX0905X | Otolaryngology/Facial Plastic Surgery Physician | — | — | Yes |

## Other

- **Enumeration date:** 05/27/2010
- **Last updated:** 05/27/2010