NPIMap

Organization Active NPI

Pinelake Physician Practice, LLC

Doing business as Jackson Purchase Podiatry

  • Internal Medicine Physician
  • Mayfield, KY
National Provider Identifier
1861563439
Registry record updated Jan 7, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
PINELAKE PHYSICIAN PRACTICE, LLC
Doing business as
Jackson Purchase Podiatry
Practice address
1029 Medical Center Cir
Mayfield, KY 42066-1189
Phone
(270) 251-4590
Fax
(270) 251-4591
NPI assigned
Nov 13, 2006
Last updated
Jan 7, 2026By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 7, 2026

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

Authorized official

Name
Charlotte Lawrence
Title
Secretary
Phone
(615) 920-7000

Specialties & licenses 15

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Physician Assistant 363A00000X
Nurse Practitioner 363L00000X
Certified Registered Nurse Anesthetist 367500000X
Lactation Consultant (Registered Nurse) 163WL0100X
Family Medicine Physician 207Q00000X
Internal Medicine Physician 207R00000X Primary
Cardiovascular Disease Physician 207RC0000X
Orthopaedic Surgery Physician 207X00000X
Facial Plastic Surgery Physician 207YS0123X
Neurology Physician 2084N0400X
Diagnostic Radiology Physician 2085R0202X
Surgery Physician 208600000X
Vascular Surgery Physician 2086S0129X
Foot & Ankle Surgery Podiatrist 213ES0103X

Addresses

Primary practice location

1029 Medical Center Cir
Mayfield, KY 42066-1189

Mailing address

330 Seven Springs Way
Atten Provider Enrollment
Brentwood, TN 37027-5098
Phone (615) 920-7000

Other practice location 1

101 Main St
Fulton, KY 42041-1601
Phone (270) 472-5245

Other practice location 2

2003 S 7th St
Hickman, KY 42050-1841

Other names 1

  • Jackson Purchase Podiatry Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in KY3 enrollments

Enrollment records 3

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
O20150213000657 KY DME Supplier - Physician - Podiatry 6800797507 Practice locations: Mayfield, KY
O20160525000413 KY Part A Provider - Rural Health Clinic 6800797507 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Hickman, KY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1861563439. Details of each certification follow.

Rural health clinic certification: CCN 188957

Legal name
PINELAKE PHYSICIAN PRACTICE LLC
Doing business as
JACKSON PURCHASE PRIMARY CARE HICKMAN CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Aug 2, 2017
Last certification
May 15, 2017
Ownership / control type
1B
Organization structure
CorporationProprietary
Incorporated
Nov 19, 1998 in DE
Enrollment address
2003 S 7TH St
Hickman, KY 42050-1841

Other NPIs with the same Medicare PAC ID 7

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 12

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

National Provider Directory

National Provider Directory

Locations

380 S Washington St
Clinton, KY 42031

101 Main St
Fulton, KY 42041
Phone (270) 472-5245

101 Main St
#1
Fulton, KY 42041

1029 Medical Center Cir
#202
Mayfield, KY 42066

1029 Medical Center Cir
Ste 20
Mayfield, KY 42066

1029 Medical Center Cir
Ste 401B
Mayfield, KY 42066
Phone (270) 251-4400

1029 Medical Dr Ste 401
Mayfield, KY 42066

1111 Medical Center Cir
#200
Mayfield, KY 42066

1111 Medical Center Cir
Ste 1
Mayfield, KY 42066

1111 Medical Center Cir
Ste Na
Mayfield, KY 42066

417 S 6th St
Bldg 1
Mayfield, KY 42066

1532 Lone Oak Rd
Ste G15
Paducah, KY 42003
Phone (270) 443-0217

Ownership & related parties

All disclosed owners & managing parties 13

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Lifepoint Holdings 2 LLC Organization, Brentwood, TN LLC, Holding company, For-profit 5% Or Greater Indirect Ownership Interest May 25, 2016 100%
Pamela Kane Individual Corporate OfficerVice President Aug 9, 2022
Lifepoint of Kentucky LLC Organization, Brentwood, TN LLC, For-profit 5% Or Greater Direct Ownership Interest May 25, 2016 100%
DSB Acquisition LLC Organization, New York, NY LLC, For-profit 5% Or Greater Indirect Ownership Interest Nov 16, 2018 100%
Laura C Hinson Individual Corporate OfficerChief Financial Officer Mar 12, 2025
Lifepoint Hospitals Holdings LLC Organization, Brentwood, TN LLC, Holding company, For-profit 5% Or Greater Indirect Ownership Interest May 25, 2016 100%
Historic Lifepoint Hospitals, LLC Organization, Brentwood, TN LLC, For-profit 5% Or Greater Indirect Ownership Interest May 25, 2016 100%
Lifepoint Health Inc Organization, Brentwood, TN Corporation, For-profit 5% Or Greater Indirect Ownership Interest Nov 16, 2018 100%
Charlotte E Lawrence Individual Corporate OfficerSecretary Jan 21, 2022
Elliott Brown Individual Corporate OfficerSenior Vice President and Treasurer Apr 2, 2026
Klaus Michael Boel Individual Corporate OfficerPresident Aug 19, 2024
W-2 Managing Employee Aug 19, 2024
Christopher J Monte Individual Corporate OfficerVice President Jan 1, 1998
Legacy Lifepoint Health LLC Organization, Brentwood, TN LLC, For-profit 5% Or Greater Indirect Ownership Interest Nov 16, 2018 100%

Practitioners & affiliated clinicians

Practitioners 57

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 57

NPI Registry JSON

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

{
    "created_epoch": "1163376000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1767744000000",
    "number": "1861563439",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "330 SEVEN SPRINGS WAY",
            "address_2": "ATTEN PROVIDER ENROLLMENT",
            "city": "BRENTWOOD",
            "state": "TN",
            "postal_code": "370275098",
            "telephone_number": "615-920-7000",
            "fax_number": "615-920-8775"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1029 MEDICAL CENTER CIR",
            "city": "MAYFIELD",
            "state": "KY",
            "postal_code": "420661189",
            "telephone_number": "270-251-4590",
            "fax_number": "270-251-4591"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "101 Main St",
            "address_purpose": "LOCATION",
            "city": "Fulton",
            "state": "KY",
            "postal_code": "420411601",
            "country_code": "US",
            "telephone_number": "270-472-5245",
            "fax_number": "270-472-5249",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "2003 S 7th St",
            "address_purpose": "LOCATION",
            "city": "Hickman",
            "state": "KY",
            "postal_code": "420501841",
            "country_code": "US",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "PINELAKE PHYSICIAN PRACTICE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-13",
        "last_updated": "2026-01-07",
        "certification_date": "2026-01-07",
        "status": "A",
        "authorized_official_last_name": "LAWRENCE",
        "authorized_official_first_name": "CHARLOTTE",
        "authorized_official_title_or_position": "SECRETARY",
        "authorized_official_telephone_number": "615-920-7000"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "367500000X",
            "taxonomy_group": "",
            "desc": "Nurse Anesthetist, Certified Registered",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "163WL0100X",
            "taxonomy_group": "",
            "desc": "Registered Nurse, Lactation Consultant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207RC0000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Cardiovascular Disease",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207X00000X",
            "taxonomy_group": "",
            "desc": "Orthopaedic Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207YS0123X",
            "taxonomy_group": "",
            "desc": "Otolaryngology, Facial Plastic Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084N0400X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Neurology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2085R0202X",
            "taxonomy_group": "",
            "desc": "Radiology, Diagnostic Radiology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208600000X",
            "taxonomy_group": "",
            "desc": "Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2086S0129X",
            "taxonomy_group": "",
            "desc": "Surgery, Vascular Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "213ES0103X",
            "taxonomy_group": "",
            "desc": "Podiatrist, Foot & Ankle Surgery",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Jackson Purchase Podiatry",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Mayfield, KY

Sources for this page

Verify at the official NPI Registry.