1891892741 NPI number — PINELAKE REGIONAL HOSPITAL LLC

Table of content: (NPI 1891892741)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891892741 NPI number — PINELAKE REGIONAL HOSPITAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINELAKE REGIONAL HOSPITAL LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
JACKSON PURCHASE MEDICAL CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891892741
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 SEVEN SPRINGS WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-5098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-920-7000
Provider Business Mailing Address Fax Number:
615-920-8913

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1099 MEDICAL CENTER CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAYFIELD
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42066-1159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-251-4100
Provider Business Practice Location Address Fax Number:
270-251-4507
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DILLON
Authorized Official First Name:
TERRANCE
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT SECRETARY
Authorized Official Telephone Number:
502-596-7220

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  100143 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282NR1301X , with the licence number: 100143 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000061925 . This is a "BCBS REFERENCE LAB" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000055031 . This is a "BCBS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 01000116 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 030016699 . This is a "USEC DEPT. OF LABOR" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 360503 . This is a "BLACK LUNG" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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