Healthcare Provider Details

I. General information

NPI: 1184603680
Provider Name (Legal Business Name): REBECCA L PENGILLY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 06/29/2021
Certification Date: 06/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 WAVERLY DR SE
ALBANY OR
97322-6952
US

IV. Provider business mailing address

444 NW ELKS DR
CORVALLIS OR
97330-3745
US

V. Phone/Fax

Practice location:
  • Phone: 541-967-8221
  • Fax:
Mailing address:
  • Phone: 541-967-8221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5123
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD182380
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: