MEDICARE: LAURIE PENHALL MACDONALD 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	208000000X	Pediatrics Physician	200100163	NC

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	:	1801862354
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURIE PENHALL MACDONALD MD

Provider Business Mailing Address
First Line	:	PO BOX 60447
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-0447
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2205 OAK RIDGE RD STE BB
Second Line	:
City	:	OAK RIDGE
State	:	NC
Zip	:	27310-8645
Country	:	US
Telephone Number	:	336-644-0994
Fax Number	:	336-644-0997

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

Provider Enumeration Date	:	02/24/2006
Last Update Date	:	03/07/2023

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