=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780160366
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PINNACLE REGIONAL HOSPITAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2018
-----------------------------------------------------
Last Update Date | 03/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17651 B HWY
-----------------------------------------------------
City | BOONVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65233-2839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-882-7461
-----------------------------------------------------
Fax | 660-882-6093
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4770 N BELLEVIEW AVE STE 205
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64116-2119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-809-8365
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING CONTACT
-----------------------------------------------------
Name | JENNIFER SKANES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 660-882-7461
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 248-47
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | 248-47
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 248-47
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------