Basic Information
| Provider Information | |||||||||
| NPI: | 1609009380 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PINNACLE DERMATOLOGY, SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5141 VIRGINIA WAY | ||||||||
| Address2: | STE 350 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6296662462 | ||||||||
| FaxNumber: | 6296662462 | ||||||||
| Practice Location | |||||||||
| Address1: | 3655 PLYMOUTH BLVD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554463664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6124864200 | ||||||||
| FaxNumber: | 6124864201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2009 | ||||||||
| LastUpdateDate: | 09/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | LAPINSKI | ||||||||
| AuthorizedOfficialFirstName: | PAULA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8157448554 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PINNACLE DERMATOLOGY, SC | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 09/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | N | Suppliers | Non-Pharmacy Dispensing Site | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 059266800 | 05 | MN | MEDICAID |