Healthcare Provider Details

I. General information

NPI: 1467538892
Provider Name (Legal Business Name): ANDREA R PENEPACKER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 S BELLEVUE AVE
DOVER OH
44622-9405
US

IV. Provider business mailing address

204 S BELLEVUE AVE
DOVER OH
44622-9405
US

V. Phone/Fax

Practice location:
  • Phone: 330-343-3321
  • Fax: 330-602-8712
Mailing address:
  • Phone: 330-343-3321
  • Fax: 330-602-8712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35-082468
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: