Provider Demographics
NPI:1194830158
Name:PENNACHIO, DOMINIC D (MD)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:D
Last Name:PENNACHIO
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 1:25 BOYLSTON ST STE 204
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467-1710
Mailing Address - Country:US
Mailing Address - Phone:617-754-0400
Mailing Address - Fax:
Practice Address - Street 1:25 BOYLSTON ST
Practice Address - Street 2:SUITE 204
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467-1715
Practice Address - Country:US
Practice Address - Phone:617-754-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA56237207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ06834OtherBLUE CROSS
MA3025691Medicaid
MAJ06834Medicare PIN
MAA59214Medicare UPIN