Healthcare Provider Details

I. General information

NPI: 1255526570
Provider Name (Legal Business Name): PHILIP A PENEPENT JR.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2007
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5196 GENESEE ST
BOWMANSVILLE NY
14026-1038
US

IV. Provider business mailing address

5196 GENESEE ST
BOWMANSVILLE NY
14026-1038
US

V. Phone/Fax

Practice location:
  • Phone: 716-681-1895
  • Fax: 716-681-5439
Mailing address:
  • Phone: 716-681-1895
  • Fax: 716-681-5439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PHILIP A PENEPENT JR.
Title or Position: SOLE PROPRIETOR
Credential: M.D.
Phone: 716-681-1895