NPIMap

Organization Active NPI

Pinelake Physician Practice LLC

Doing business as Jackson Purchase ENT & Aesthetic Surgery

  • Otolaryngology/Facial Plastic Surgery Physician
  • Mayfield, KY
National Provider Identifier
1255650479
Registry record updated May 27, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Otolaryngology/Facial Plastic Surgery PhysicianTaxonomy code 207YX0905X
Legal business name
PINELAKE PHYSICIAN PRACTICE LLC
Doing business as
Jackson Purchase ENT & Aesthetic Surgery
Practice address
1111 Medical Center Cir
Mayfield, KY 42066-1194
Phone
(270) 251-4080
Fax
(270) 251-4081
NPI assigned
May 27, 2010
Last updated
May 27, 2010By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 27, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Timothy D Vaughn
Title
Vice President
Phone
(615) 372-8500

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Otolaryngology/Facial Plastic Surgery Physician 207YX0905X NU Primary

Addresses

Primary practice location

1111 Medical Center Cir
Mayfield, KY 42066-1194

Mailing address

1029 Medical Center Cir
Mayfield, KY 42066-1189
Phone (270) 251-4080

Other names 1

  • Jackson Purchase ENT & Aesthetic Surgery Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in KY

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040115001094 KY Part B Supplier - Clinic/Group Practice 6800797507 Receives reassigned benefits from 71 practitioners
12 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Benton, KY; Paducah, KY; Mayfield, KY; Hickman, KY; Fulton, KY; Clinton, KY

Other NPIs on the same Medicare enrollment 12

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
18D2010708Jackson Purchase ENT & Aesthetic Surgery1111 Medical Center Circle, Mayfield, KY 42066Certificate of waiverAug 2, 2026

National Provider Directory

National Provider Directory

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1274918400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1274918400000",
    "number": "1255650479",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1029 MEDICAL CENTER CIR",
            "city": "MAYFIELD",
            "state": "KY",
            "postal_code": "420661189",
            "telephone_number": "270-251-4080",
            "fax_number": "270-251-4081"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1111 MEDICAL CENTER CIR",
            "city": "MAYFIELD",
            "state": "KY",
            "postal_code": "420661194",
            "telephone_number": "270-251-4080",
            "fax_number": "270-251-4081"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PINELAKE PHYSICIAN PRACTICE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-05-27",
        "last_updated": "2010-05-27",
        "status": "A",
        "authorized_official_last_name": "VAUGHN",
        "authorized_official_first_name": "TIMOTHY",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "VICE PRESIDENT",
        "authorized_official_telephone_number": "615-372-8500"
    },
    "taxonomies": [
        {
            "code": "207YX0905X",
            "taxonomy_group": "",
            "desc": "Otolaryngology, Otolaryngology/Facial Plastic Surgery",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Jackson Purchase ENT & Aesthetic Surgery",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Mayfield, KY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 27, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.