MEDICARE: DR. ANDRE MICHAEL PENNARDT M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	9900962	NC
2	207P00000X	Emergency Medicine Physician	036592	GA
3	207P00000X	Emergency Medicine Physician	ME112439	FL
4	207P00000X	Emergency Medicine Physician	35909	MT

General Provider Information

NPI Number	:	1174502280
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANDRE MICHAEL PENNARDT M.D.

Provider Business Mailing Address
First Line	:	401 W PENNSYLVANIA AVE
Second Line	:
City	:	ANACONDA
State	:	MT
Zip	:	59711-1931
Country	:	US
Telephone Number	:	406-563-8585
Fax Number	:

Provider Business Practice Location Address
First Line	:	401 W PENNSYLVANIA AVE
Second Line	:
City	:	ANACONDA
State	:	MT
Zip	:	59711-1931
Country	:	US
Telephone Number	:	406-563-8585
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/17/2006
Last Update Date	:	09/01/2016

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