1760813034 NPI number — E. EARL PENNINGTON, MD, LLC

Table of content: (NPI 1760813034)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760813034 NPI number — E. EARL PENNINGTON, MD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
E. EARL PENNINGTON, MD, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1760813034
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3890 JOHNS CREEK PKWY
Provider Second Line Business Mailing Address:
SUITE 360
Provider Business Mailing Address City Name:
SUWANEE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30024-1284
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-954-8538
Provider Business Mailing Address Fax Number:
770-244-9204

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3890 JOHNS CREEK PKWY
Provider Second Line Business Practice Location Address:
SUITE 360
Provider Business Practice Location Address City Name:
SUWANEE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30024-1284
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-954-8538
Provider Business Practice Location Address Fax Number:
770-244-9204
Provider Enumeration Date:
12/11/2013

Additional Information

Authorized Official

Authorized Official Last Name:
PENNINGTON
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
EARL
Authorized Official Title or Position:
PHYSICIAN/MANAGER
Authorized Official Telephone Number:
678-954-8538

Provider Taxonomy Codes

  • Taxonomy code: 208C00000X , with the licence number:  015299 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00098084B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com