Healthcare Provider Details

I. General information

NPI: 1497982110
Provider Name (Legal Business Name): FRANK JOHN PENNA III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2009
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 RICHLAND MEDICAL PARK DR STE 500
COLUMBIA SC
29203-6870
US

IV. Provider business mailing address

PO BOX 743904
ATLANTA GA
30374-3904
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-2833
  • Fax: 803-434-2834
Mailing address:
  • Phone: 803-296-7320
  • Fax: 803-296-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number4301094191
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number17727
License Number StateNH
# 3
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number83812
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: