Basic Information
| Provider Information | |||||||||
| NPI: | 1144313669 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PINNACLE ANESTHESIA ASSOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3750 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841103750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883046796 | ||||||||
| FaxNumber: | 8014322670 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 N HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | PRICE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356374800 | ||||||||
| FaxNumber: | 8014322670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 09/14/2009 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
| AuthorizedOfficialMiddleName: | WILLIAM | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8883046796 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 27041325001 | 05 | UT | MEDICAID |