Healthcare Provider Details

I. General information

NPI: 1780873547
Provider Name (Legal Business Name): ROBERT ELDEN PENNINGTON MD, PHD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 EL ARCO IRIS DR
ROSWELL NM
88201-7711
US

IV. Provider business mailing address

1 EL ARCO IRIS DR
ROSWELL NM
88201-7711
US

V. Phone/Fax

Practice location:
  • Phone: 505-625-5512
  • Fax: 505-625-1013
Mailing address:
  • Phone: 505-625-5512
  • Fax: 505-625-1013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number95321
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number95321
License Number StateNM

VIII. Authorized Official

Name: DR. ROBERT PENNINGTON
Title or Position: PHYSICIAN OWNER
Credential: M.D., PHD
Phone: 505-625-5512