MEDICARE: DR. MICHAELE MARY PENKOSKE 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	207R00000X	Internal Medicine Physician	R9818	MO

General Provider Information

NPI Number	:	1477926624
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAELE MARY PENKOSKE M. D.

Provider Business Mailing Address
First Line	:	24 LAKE FOREST DR
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63301-4524
Country	:	US
Telephone Number	:	314-397-6244
Fax Number	:

Provider Business Practice Location Address
First Line	:	24 LAKE FOREST DR
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63301-4524
Country	:	US
Telephone Number	:	314-397-6244
Fax Number	:

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

Provider Enumeration Date	:	11/10/2015
Last Update Date	:	11/10/2015

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