Healthcare Provider Details

I. General information

NPI: 1487166757
Provider Name (Legal Business Name): RICHARD PENNINGTON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2017
Last Update Date: 02/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 N WABASH AVE
MARION IN
46952-2612
US

IV. Provider business mailing address

3442 S LINCOLN BLVD
MARION IN
46953-4504
US

V. Phone/Fax

Practice location:
  • Phone: 765-660-6000
  • Fax:
Mailing address:
  • Phone: 765-506-7553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28201310A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: