Provider Demographics
NPI:1114339728
Name:PENCE, MICHAEL PHILLIP (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PHILLIP
Last Name:PENCE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:948 NAPIERS POST DR
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-6428
Mailing Address - Country:US
Mailing Address - Phone:717-926-1759
Mailing Address - Fax:
Practice Address - Street 1:3651 WHEELER RD DEPT OF
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6521
Practice Address - Country:US
Practice Address - Phone:706-651-3232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-30
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS017860207L00000X
GA84420207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIVAD000Medicare UPIN