MEDICARE: DR. RICHARD SIDDALL PENNEBAKER 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
1	208000000X	Pediatrics Physician	12799	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356399604
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD SIDDALL PENNEBAKER M.D.

Provider Business Mailing Address
First Line	:	ONE INDEPENDENCE POINTE
Second Line	:	SUITE 212
City	:	GREENVILLE
State	:	SC
Zip	:	29615-4566
Country	:	US
Telephone Number	:	864-797-6044
Fax Number	:	864-797-6198

Provider Business Practice Location Address
First Line	:	57 CROSS PARK COURT
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29605-4264
Country	:	US
Telephone Number	:	864-797-6044
Fax Number	:	864-797-6198

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

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	09/14/2011

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Directions to “ DR. RICHARD SIDDALL PENNEBAKER M.D.” Practice Location

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