Provider Demographics
NPI:1205006343
Name:PINNACLE RADIOLOGY LLC
Entity Type:Organization
Organization Name:PINNACLE RADIOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:S
Authorized Official - Last Name:HAZLETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-799-9172
Mailing Address - Street 1:PO BOX 881839
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34988-1839
Mailing Address - Country:US
Mailing Address - Phone:727-896-3134
Mailing Address - Fax:770-666-9330
Practice Address - Street 1:490 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2871
Practice Address - Country:US
Practice Address - Phone:321-268-4200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAM098OtherMEDICARE PTAN