Provider Demographics
NPI:1275610198
Name:PENNER, GREGORY L (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:L
Last Name:PENNER
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 1:331 MAINE ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-3358
Mailing Address - Country:US
Mailing Address - Phone:207-721-0911
Mailing Address - Fax:207-721-9729
Practice Address - Street 1:331 MAINE ST STE 4
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-3359
Practice Address - Country:US
Practice Address - Phone:207-721-0911
Practice Address - Fax:207-721-9729
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME12949174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME017636OtherBS
ME1027557OtherAETNA
ME122050000Medicaid
MEMM3075Medicare PIN
MEE400187362Medicare PIN
ME017636OtherBS
MEE400187362Medicare PIN