1144200684 NPI number — KENNETH L PENNINGTON M.D.

Table of content: KENNETH L PENNINGTON M.D. (NPI 1144200684)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144200684 NPI number — KENNETH L PENNINGTON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENNINGTON
Provider First Name:
KENNETH
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144200684
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3702 NEW VISION DR
Provider Second Line Business Mailing Address:
BLDG B
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46845-1703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-266-8210
Provider Business Mailing Address Fax Number:
574-364-2759

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 HIGH PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOSHEN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46526-4810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-535-2888
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  01024970 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RX0202X , with the licence number: 01024970A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100138820 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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