Pinelake Physician Practice, LLC
Organization Active NPI Rural Health Clinic/Center · Mayfield, KY
NPI 1841900347 · NPPES record last updated Nov 25, 2022
Key facts
- NPI
- 1841900347
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- PINELAKE PHYSICIAN PRACTICE, LLC
- Practice address
- 1029 Medical Center Cir Ste 204
Mayfield, KY 42066-1189 - Phone
- (270) 251-4545
- NPI assigned
- Nov 25, 2022
- Organization subpart
- No
Authorized official
- Name
- Charlotte Lawrence
- Title
- Assistant Corporate Secretary
- Phone
- (615) 920-7688
Other NPIs on the same Medicare enrollment 12
Other NPIs with the same Medicare PAC ID 7
Corporate family (same tax ID) 8
Facilities with the same owner 193
Practitioners 73
-
Allie Alexander-Lusk, APRN
-
Bethanie M Apperson, APRN
-
Heather D Ballard, APRN
-
Jennifer Bartley, APRN
-
Christa Dabren Bewley, PMHNP
-
Puneet Bhatia, M.D.
-
Ruben Cuadrado, MD
-
Tyrone L Daniels, MD
-
Sarah Darnell, APRN, FNP-BC
-
Christopher D Dobrose, M.D.
-
Brian Thomas Farrell, M.D./PH.D.
-
Mary Graham, APRN
-
Michelle Ann Jewell, APRN
-
David W Koury, M.D.
-
Jessica M Little, DPM
-
Elias Pitaras, M.D.
-
Matthew E Price, MD
-
Sandy Kay Riley, APRN
-
Brandi N Rose, FNP-C
-
Nicole Schmidt, APRN
-
Brandi L Stacy, APRN
-
Anita Torok, MD
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 18D0923105 | Jackson Purchase Primary Care - Convenient Care | Certificate of waiver | Nov 30, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in KY
Rural health clinic certification: CCN B03926
- Legal name
- PINELAKE PHYSICIAN PRACTICE LLC
- Doing business as
- JACKSON PURCHASE PRIMARY CARE-PURCHASE CONVENIENT CARE
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Jul 7, 2023
- Last certification
- Jul 7, 2023
- Ownership / control type
- 1B
- Organization structure
- LLC · Proprietary
- Incorporated
- Nov 19, 1988 in KY
- Enrollment address
- 1029 Medical Center Cir
Ste 202
Mayfield, KY 42066-1189
All disclosed owners & managing parties 13
| Name | Role | Since | Share |
|---|---|---|---|
| Lifepoint Holdings 2 LLC |
5% Or Greater Indirect Ownership Interest | Jan 1, 2023 | 100% |
| Pamela Kane |
Corporate Officer |
Jan 1, 2023 | |
| Lifepoint of Kentucky LLC |
5% Or Greater Direct Ownership Interest | Jan 1, 2023 | 100% |
| DSB Acquisition LLC |
5% Or Greater Indirect Ownership Interest | Jan 1, 2023 | 100% |
| Laura C Hinson |
Corporate Officer |
Mar 12, 2025 | |
| Lifepoint Hospitals Holdings LLC |
5% Or Greater Direct Ownership Interest | Jan 1, 2023 | 100% |
| Historic Lifepoint Hospitals, LLC |
5% Or Greater Indirect Ownership Interest | Jan 1, 2023 | 100% |
| Lifepoint Health Inc |
5% Or Greater Indirect Ownership Interest | Jan 1, 2023 | 100% |
| Charlotte E Lawrence |
Corporate Officer |
Jan 1, 2023 | |
| Elliott Brown |
Corporate Officer |
Apr 2, 2026 | |
| Klaus Michael Boel |
Corporate Officer |
Aug 19, 2024 | |
| W-2 Managing Employee | Aug 19, 2024 | ||
| Christopher J Monte |
Corporate Officer |
Jan 1, 2023 | |
| Legacy Lifepoint Health LLC |
5% Or Greater Indirect Ownership Interest | Jan 1, 2023 | 100% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 |
| O20230125002844 | KY | Part a Provider - Rural Health Clinic | 6800797507 | Practice locations: Mayfield, KY |
National Provider Directory
- Tax ID family
- Dale W Kesl DO
Locations
380 S Washington St
Ste 200
Clinton, KY 42031
Phone (270) 653-0220
309 Main St
Fulton, KY 42041
Phone (270) 472-2294
1029 Medical Center Cir
Ste 401
Mayfield, KY 42066
Phone (270) 251-4590
1029 Medical Center Cir
Ste 204
Mayfield, KY 42066
Phone (270) 251-4545
1029 Medical Center Cir
#200A
Mayfield, KY 42066
Phone (270) 251-4545
1029 Medical Center Cir
Ste 401A
Mayfield, KY 42066
Phone (270) 251-4575
1532 Lone Oak Rd
Ste G15
Paducah, KY 42003
Phone (270) 443-0217
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
1029 Medical Center Cir Ste 204
Mayfield, KY 42066-1189
Mailing address
330 Seven Springs Way
Brentwood, TN 37027-5098
Phone (615) 920-7000
Other providers in Mayfield, KY
- Pinelake Physician Practice LLC
- Pinelake Physician Practice LLC
- Pinelake Physician Practice LLC
- Pinelake Physician Practice LLC
- Pinelake Physician Practice, LLC
- Pinelake Physician Practice, LLC
- Pinelake Physician Practice, LLC
- Pinelake Physician Practice, LLC
- Pinelake Physician Practices LLC
- Pinelake Regional Hospital LLC
All providers in Mayfield, KY · Rural Health Clinic/Center in Kentucky
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 25, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.