Healthcare Provider Details

I. General information

NPI: 1326139627
Provider Name (Legal Business Name): PENN TECK DIAGNOSTICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 05/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 ST. SEBASTIAN WAY, SUITE 2B
AUGUSTA GA
30901
US

IV. Provider business mailing address

820 ST. SEBASTIAN WAY, SUITE 2B
AUGUSTA GA
30901
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 TaxonomyY
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number014977
License Number StateGA

VIII. Authorized Official

Name: MR. WEEMS R PENNINGTON JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 706-722-6612