Provider Demographics
NPI:1265644876
Name:PINNACLE FAMILY MEDICINE PA
Entity Type:Organization
Organization Name:PINNACLE FAMILY MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:C
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD MBA
Authorized Official - Phone:352-688-2118
Mailing Address - Street 1:120 MEDICAL BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-0220
Mailing Address - Country:US
Mailing Address - Phone:352-688-2118
Mailing Address - Fax:352-688-3118
Practice Address - Street 1:120 MEDICAL BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34609-0220
Practice Address - Country:US
Practice Address - Phone:352-688-2118
Practice Address - Fax:352-688-3118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88431207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK5407OtherMEDICARE ID
FL37656OtherBCBS