Provider Demographics
NPI:1073262168
Name:PINNACLE HEALTH GROUP PA
Entity Type:Organization
Organization Name:PINNACLE HEALTH GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:DIASTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-874-5500
Mailing Address - Street 1:PO BOX 18344
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33679-8344
Mailing Address - Country:US
Mailing Address - Phone:813-874-5500
Mailing Address - Fax:813-874-5505
Practice Address - Street 1:1601 W REYNOLDS ST STE 201
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-4747
Practice Address - Country:US
Practice Address - Phone:813-874-5500
Practice Address - Fax:813-874-5505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-23
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL27330300Medicaid
FLME71925OtherMEDICAL LICENSE