MEDICARE: PINNACLE PLASTIC SURGERY ASSOCIATES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician
2	208200000X	Plastic Surgery Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265871719
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINNACLE PLASTIC SURGERY ASSOCIATES LLC

Provider Business Mailing Address
First Line	:	7 MALLETT WAY
Second Line	:
City	:	BLUFFTON
State	:	SC
Zip	:	29910-6064
Country	:	US
Telephone Number	:	843-815-6699
Fax Number	:	843-815-6695

Provider Business Practice Location Address
First Line	:	7 MALLETT WAY
Second Line	:
City	:	BLUFFTON
State	:	SC
Zip	:	29910-6064
Country	:	US
Telephone Number	:	843-815-6699
Fax Number	:	843-815-6695

Authorized Official
Title or Position	:	OWNER
Name	:	DR. AUDREY ANNE KLENKE
Credential	:	M.D.
Telephone Number	:	843-815-6699

Provider Enumeration Date	:	06/18/2013
Last Update Date	:	01/30/2020

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