1053066936 NPI number — PINNACLE FAMILY CARE PRACTICE

Table of content: (NPI 1053066936)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053066936 NPI number — PINNACLE FAMILY CARE PRACTICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINNACLE FAMILY CARE PRACTICE
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:
6
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:
1053066936
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10220 S DOLFIELD RD STE 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OWINGS MILLS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21117-3660
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-912-5077
Provider Business Mailing Address Fax Number:
410-835-7865

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5835 YORK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21212-3612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-912-5077
Provider Business Practice Location Address Fax Number:
410-835-7865
Provider Enumeration Date:
02/18/2022

Additional Information

Authorized Official

Authorized Official Last Name:
POPOOLA
Authorized Official First Name:
ADENIKE
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
MANAGING DIRECTOR
Authorized Official Telephone Number:
443-527-1497

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 622039800 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: R224315 . This is a "FAMILY MEDICINE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com