Healthcare Provider Details

I. General information

NPI: 1356399604
Provider Name (Legal Business Name): RICHARD SIDDALL PENNEBAKER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 09/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 CROSS PARK COURT
GREENVILLE SC
29605-4264
US

IV. Provider business mailing address

ONE INDEPENDENCE POINTE SUITE 212
GREENVILLE SC
29615-4566
US

V. Phone/Fax

Practice location:
  • Phone: 864-797-6044
  • Fax: 864-797-6198
Mailing address:
  • Phone: 864-797-6044
  • Fax: 864-797-6198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number12799
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: