Basic Information
| Provider Information | |||||||||
| NPI: | 1750586624 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHRISTOPHER F. PENKA, M.D., P.A., INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4403 HARRISON BLVD STE 1815 | ||||||||
| Address2: | |||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844033271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013876520 | ||||||||
| FaxNumber: | 8013876557 | ||||||||
| Practice Location | |||||||||
| Address1: | 4403 HARRISON BLVD STE 1815 | ||||||||
| Address2: | |||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844033271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013876520 | ||||||||
| FaxNumber: | 8013876557 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PENKA | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN SURGEON | ||||||||
| AuthorizedOfficialTelephone: | 8013876520 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 811667271205 | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 556809063000 | 05 | UT | MEDICAID |