Healthcare Provider Details

I. General information

NPI: 1386092559
Provider Name (Legal Business Name): PENN HEART LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2016
Last Update Date: 05/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 SAINT SEBASTIAN WAY STE 2B
AUGUSTA GA
30901-2643
US

IV. Provider business mailing address

820 SAINT SEBASTIAN WAY STE 2B
AUGUSTA GA
30901-2643
US

V. Phone/Fax

Practice location:
  • Phone: 706-722-6612
  • Fax: 706-722-5057
Mailing address:
  • Phone: 706-722-6612
  • Fax: 706-722-5057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: WEEMS R PENNINGTON JR.
Title or Position: PRESIDENT/OWNER
Credential: MD
Phone: 706-210-9990