1205006343 NPI number — PINNACLE RADIOLOGY LLC

Table of content: (NPI 1205006343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205006343 NPI number — PINNACLE RADIOLOGY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINNACLE RADIOLOGY 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:
Provider Other Organization Name Type Code:
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:
1205006343
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 881839
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ST LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34988-1839
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-896-3134
Provider Business Mailing Address Fax Number:
770-666-9330

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
490 N WASHINGTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TITUSVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32796-2871
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-268-4200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/05/2008

Additional Information

Authorized Official

Authorized Official Last Name:
HAZLETT
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
S
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
321-799-9172

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: AM098 . This is a "MEDICARE PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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