Provider Demographics
| NPI: | 1316963077 |
|---|---|
| Name: | PINNACLE MEDICAL GROUP PA |
| Entity type: | Organization |
| Organization Name: | PINNACLE MEDICAL GROUP PA |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | PRESIDENT |
| Authorized Official - Prefix: | DR |
| Authorized Official - First Name: | MARC |
| Authorized Official - Middle Name: | STEPHEN |
| Authorized Official - Last Name: | KALLINS |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | MD |
| Authorized Official - Phone: | 941-750-0602 |
| Mailing Address - Street 1: | 315 75TH ST W |
| Mailing Address - Street 2: | |
| Mailing Address - City: | BRADENTON |
| Mailing Address - State: | FL |
| Mailing Address - Zip Code: | 34209-3201 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 941-761-1998 |
| Mailing Address - Fax: | 941-761-0395 |
| Practice Address - Street 1: | 315 75TH ST W |
| Practice Address - Street 2: | |
| Practice Address - City: | BRADENTON |
| Practice Address - State: | FL |
| Practice Address - Zip Code: | 34209-3201 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 941-761-1998 |
| Practice Address - Fax: | 941-761-0395 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-07-15 |
| Last Update Date: | 2010-07-16 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| FL | ME40567 | 208100000X |
| FL | PY6258 | 103G00000X |
| FL | ME44610 | 207R00000X |
| FL | ME74784 | 207X00000X |
| FL | ME68033 | 207T00000X |
| FL | ME64188 | 207RR0500X |
| FL | ME72170 | 2084N0400X |
| FL | ME11749 | 207RC0000X |
| FL | ME34789 | 207P00000X |
| FL | PT18064 | 225100000X |
| FL | ME13523 | 207Q00000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
| No | 103G00000X | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 207T00000X | Allopathic & Osteopathic Physicians | Neurological Surgery | Group - Multi-Specialty | |
| No | 207RR0500X | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | Group - Multi-Specialty |
| No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
| No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
| No | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine | Group - Multi-Specialty | |
| No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| FL | 254897605 | Medicaid | |
| FL | CH1832 | Other | MEDICARE RAILROAD |
| FL | 254897600 | Medicaid | |
| FL | 254897602 | Medicaid | |
| FL | 254897603 | Medicaid | |
| FL | CN7277 | Other | MEDICARE RAILROAD |
| FL | 21818 | Other | BCBS |
| FL | 254897601 | Medicaid | |
| FL | 254897604 | Medicaid | |
| FL | 254897600 | Medicaid | |
| FL | 254897605 | Medicaid | |
| FL | 21818D | Medicare PIN | |
| FL | 21818A | Medicare PIN | |
| FL | 254897603 | Medicaid | |
| FL | 21818B | Medicare PIN | |
| FL | 21818 | Medicare PIN | |
| FL | 21818F | Medicare PIN | |
| FL | 254897601 | Medicaid |
