MEDICARE: DR. GREGORY K PENNOCK MD

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	207RH0003X	Hematology & Oncology Physician	ME90972	FL

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	:	1598749293
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY K PENNOCK MD

Provider Business Mailing Address
First Line	:	PO BOX 13925
Second Line	:
City	:	BELFAST
State	:	ME
Zip	:	04915-4030
Country	:	US
Telephone Number	:	904-389-4105
Fax Number	:	904-202-7377

Provider Business Practice Location Address
First Line	:	1235 SAN MARCO BLVD
Second Line	:	SUITE 2
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-8554
Country	:	US
Telephone Number	:	904-202-7300
Fax Number	:	904-202-7377

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

Provider Enumeration Date	:	12/06/2005
Last Update Date	:	11/16/2015

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