Organization
PINELAKE PHYSICIAN PRACTICE, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MONICA BOWMAN (SR. DIRECTOR)
(615) 920-7000
Entity
Organization
Contact information
Practice address
1111 MEDICAL CENTER CIR, MAYFIELD, KY 42066-1194
(270) 251-4543
(270) 251-4544
Mailing address
330 SEVEN SPRINGS WAY, ATTEN: PROVIDER ENROLLMENT, BRENTWOOD, TN 37027-5098
(615) 920-7192
(615) 920-8775
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
—
—
261QR1300X
Rural Health Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000618910
ANTHEM
KY
05
—
7100335050
—
KY
Enumeration date
05/15/2009
Last updated
05/08/2023
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