Basic Information
| Provider Information | |||||||||
| NPI: | 1891784724 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PENNEBACKER | ||||||||
| FirstName: | PAIGE | ||||||||
| MiddleName: | KOENIG | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14731 | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342804731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417610500 | ||||||||
| FaxNumber: | 9417610400 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 75TH ST W | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342093201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417610500 | ||||||||
| FaxNumber: | 8555212857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2005 | ||||||||
| LastUpdateDate: | 10/03/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | ME62365 | FL | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.