Healthcare Provider Details

I. General information

NPI: 1871364646
Provider Name (Legal Business Name): PENIEL INTERVENTIONAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2024
Last Update Date: 01/11/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 SPRY ISLAND RD
JOPPA MD
21085-5424
US

IV. Provider business mailing address

318 SPRY ISLAND RD
JOPPA MD
21085-5424
US

V. Phone/Fax

Practice location:
  • Phone: 317-797-9816
  • Fax:
Mailing address:
  • Phone: 113-177-9798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: ELSIE ANTWIWAA TWENEBOAH-KODUAH
Title or Position: OWNER
Credential: FNP-BC
Phone: 317-797-9816