MEDICARE: JACK R. PENCE II 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	208800000X	Urology Physician	35-043064	OH
2	208800000X	Urology Physician	35043064	OH
3	208800000X	Urology Physician	35043064P	OH

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	:	1851399414
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK R. PENCE II MD

Provider Business Mailing Address
First Line	:	6680 POE AVE
Second Line	:	SUITE 200
City	:	DAYTON
State	:	OH
Zip	:	45414-2854
Country	:	US
Telephone Number	:	937-280-8366
Fax Number	:	937-280-8373

Provider Business Practice Location Address
First Line	:	1911 N FAIRFIELD RD
Second Line	:	SUITE 300
City	:	BEAVERCREEK
State	:	OH
Zip	:	45432-2762
Country	:	US
Telephone Number	:	937-429-7352
Fax Number	:	937-429-3772

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

Provider Enumeration Date	:	07/08/2005
Last Update Date	:	03/17/2014

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Directions to “ JACK R. PENCE II MD” Practice Location

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