Provider Demographics
NPI:1235365081
Name:PENNINGTON, ELLIOT CARR (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLIOT
Middle Name:CARR
Last Name:PENNINGTON
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 1:330 BARCLAY AVE NE STE 201
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2525
Mailing Address - Country:US
Mailing Address - Phone:616-458-1722
Mailing Address - Fax:
Practice Address - Street 1:330 BARCLAY AVE NE STE 202
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2525
Practice Address - Country:US
Practice Address - Phone:616-443-8007
Practice Address - Fax:616-458-0061
Is Sole Proprietor?:No
Enumeration Date:2009-06-08
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU21042086S0120X
MI12353650812086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery