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NPI Code Detail

MEDICARE: JOHN PENUEL M.D.

MEDICARE: JOHN PENUEL M.D.
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
1174400000XSpecialist9900983NC
22085R0202XDiagnostic Radiology Physician048926GA

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
4P00991552OTHERGARR MEDICARE

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2048926OTHERGALICENSE
3581593676OTHERGATAX IDENTIFICATION

General Provider Information

NPI Number : 1285633842
Entity Type Code : Individual
Provider Name (Legal Business Name) : JOHN PENUEL M.D.
Provider Business Mailing Address
First Line : 1854 SHACKLEFORD CT
Second Line : SUITE 350
City : NORCROSS
State : GA
Zip : 30093-2954
Country : US
Telephone Number : 770-688-3801
Fax Number : 770-237-6148
Provider Business Practice Location Address
First Line : 821 N COBB ST
Second Line :
City : MILLEDGEVILLE
State : GA
Zip : 31061-2343
Country : US
Telephone Number : 478-452-0524
Fax Number : 478-452-0525
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/18/2005
Last Update Date : 03/07/2023

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