1477062677 NPI number — PINNACLE PAIN & SPINE CONSULTANTS, PLC

Table of content: (NPI 1477062677)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477062677 NPI number — PINNACLE PAIN & SPINE CONSULTANTS, PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINNACLE PAIN & SPINE CONSULTANTS, PLC
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:
PINNACLE PAIN & SPINE CONSULTANTS, PLC-DME
Provider Other Organization Name Type Code:
3
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:
1477062677
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17505 N 79TH AVE STE 304A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85308-8729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-407-6402
Provider Business Mailing Address Fax Number:
623-777-7169

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9023 E DESERT COVE AVE STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCOTTSDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85260-6779
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-407-6400
Provider Business Practice Location Address Fax Number:
480-407-6520
Provider Enumeration Date:
09/20/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CROOKS
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN OWNER
Authorized Official Telephone Number:
480-407-6400

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  42847 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 287745 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".