Healthcare Provider Details

I. General information

NPI: 1700863941
Provider Name (Legal Business Name): ROBERT J. PENNY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 01/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E MEDICAL CENTER DR 2ND FLOOR UNIVERSITY HOSPITAL RECP PATHOLOGY
ANN ARBOR MI
48109-5000
US

IV. Provider business mailing address

3621 S STATE ST 700 KMS PLACE
ANN ARBOR MI
48108-1633
US

V. Phone/Fax

Practice location:
  • Phone: 800-862-7284
  • Fax: 734-615-2964
Mailing address:
  • Phone: 734-936-2047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number01037347A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number4301102040
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number4301102040
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: