Basic Information
| Provider Information | |||||||||
| NPI: | 1316963077 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PINNACLE MEDICAL GROUP PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 75TH ST W | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342093201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417611998 | ||||||||
| FaxNumber: | 9417610395 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 75TH ST W | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342093201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417611998 | ||||||||
| FaxNumber: | 9417610395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 07/16/2010 | ||||||||
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| AuthorizedOfficialLastName: | KALLINS | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | STEPHEN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9417500602 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | ME40567 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 103G00000X | PY6258 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 207R00000X | ME44610 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207X00000X | ME74784 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207T00000X | ME68033 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery | 207RR0500X | ME64188 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 2084N0400X | ME72170 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 207RC0000X | ME11749 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207P00000X | ME34789 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 225100000X | PT18064 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 207Q00000X | ME13523 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 254897605 | 05 | FL | MEDICAID | CH1832 | 01 | FL | MEDICARE RAILROAD | OTHER | 254897600 | 05 | FL | MEDICAID | 254897602 | 05 | FL | MEDICAID | 254897603 | 05 | FL | MEDICAID | CN7277 | 01 | FL | MEDICARE RAILROAD | OTHER | 21818 | 01 | FL | BCBS | OTHER | 254897601 | 05 | FL | MEDICAID | 254897604 | 05 | FL | MEDICAID |