Provider Demographics
NPI:1174502280
Name:PENNARDT, ANDRE MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDRE
Middle Name:MICHAEL
Last Name:PENNARDT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 W PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:ANACONDA
Mailing Address - State:MT
Mailing Address - Zip Code:59711-1931
Mailing Address - Country:US
Mailing Address - Phone:406-563-8585
Mailing Address - Fax:
Practice Address - Street 1:401 W PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:ANACONDA
Practice Address - State:MT
Practice Address - Zip Code:59711-1931
Practice Address - Country:US
Practice Address - Phone:406-563-8585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900962207P00000X
GA036592207P00000X
FLME112439207P00000X
MT35909207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H28596Medicare UPIN