1215027263 NPI number — DR. WEEMS R PENNINGTON III MD

Table of content: DR. WEEMS R PENNINGTON III MD (NPI 1215027263)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215027263 NPI number — DR. WEEMS R PENNINGTON III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENNINGTON
Provider First Name:
WEEMS
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
MD
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:
1215027263
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
367 S. GULPH RD
Provider Second Line Business Mailing Address:
ATT: IPM CREDENTIALING
Provider Business Mailing Address City Name:
KING OF PRUSSIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19406-3121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-641-4874
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
137 MIRACLE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AIKEN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29801-6351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-641-4874
Provider Business Practice Location Address Fax Number:
803-641-0436
Provider Enumeration Date:
10/13/2006

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: 207RC0000X , with the licence number:  59309 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: 22253 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: G59309 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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