Basic Information
| Provider Information | |||||||||
| NPI: | 1255526570 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHILIP A PENEPENT JR. MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5196 GENESEE ST | ||||||||
| Address2: | |||||||||
| City: | BOWMANSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140261038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166811895 | ||||||||
| FaxNumber: | 7166815439 | ||||||||
| Practice Location | |||||||||
| Address1: | 5196 GENESEE ST | ||||||||
| Address2: | |||||||||
| City: | BOWMANSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140261038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166811895 | ||||||||
| FaxNumber: | 7166815439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2007 | ||||||||
| LastUpdateDate: | 09/10/2007 | ||||||||
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| AuthorizedOfficialLastName: | PENEPENT | ||||||||
| AuthorizedOfficialFirstName: | PHILIP | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE PROPRIETOR | ||||||||
| AuthorizedOfficialTelephone: | 7166811895 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00751193 | 05 | NY | MEDICAID |