=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750825816
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PINNACLE MEDICAL, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2016
-----------------------------------------------------
Last Update Date | 12/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 STATE ROUTE 35
-----------------------------------------------------
City | RED BANK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07701-5018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-977-1156
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1317 ROUTE 73
-----------------------------------------------------
City | MOUNT LAUREL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08054-2202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-439-6111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | TREASURER
-----------------------------------------------------
Name | SCOTT COHEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 856-439-6111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------