=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487358941
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PINNACLE ANESTHESIA GROUP, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2023
-----------------------------------------------------
Last Update Date | 03/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3721 S CHAMPIONS DR
-----------------------------------------------------
City | ROGERS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72758-8713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-870-6125
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4452 W HIDDEN ACRES CT
-----------------------------------------------------
City | ROGERS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72758-6010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-426-6744
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | MR. JUSTIN SLADE BRIDWELL
-----------------------------------------------------
Credential | CRNA
-----------------------------------------------------
Telephone | 479-426-6744
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------