Healthcare Provider Details

I. General information

NPI: 1972501450
Provider Name (Legal Business Name): SCOTT PENNINGTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 11/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 REID PARKWAY ANESTHESIA/SURGERY DEPARTMENT
RICHMOND IN
47374-1157
US

IV. Provider business mailing address

1100 REID PARKWAY MEDICAL STAFF SERVICES
RICHMOND IN
47374-1157
US

V. Phone/Fax

Practice location:
  • Phone: 765-935-8807
  • Fax: 765-983-3219
Mailing address:
  • Phone: 765-983-3127
  • Fax: 765-983-3219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number01042814
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: