MEDICARE: JENNIFER ANNE PENNINGTON D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	02003207A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P00734479	OTHER	IN	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000533533	OTHER	IN	BCBS BMG SCHWARTZ-WIEKAMP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114145687
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER ANNE PENNINGTON D.O.

Provider Business Mailing Address
First Line	:	710 N NILES AVE
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46617-1924
Country	:	US
Telephone Number	:	574-647-1610
Fax Number	:

Provider Business Practice Location Address
First Line	:	4630 VISTULA RD
Second Line	:
City	:	MISHAWAKA
State	:	IN
Zip	:	46544-4000
Country	:	US
Telephone Number	:	574-647-1900
Fax Number	:	574-254-7222

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2007
Last Update Date	:	03/31/2021

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Directions to “ JENNIFER ANNE PENNINGTON D.O.” Practice Location

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