Provider Demographics
NPI:1316006760
Name:WENNER, ALLEN RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:RICHARD
Last Name:WENNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1624 MAIN STREET
Mailing Address - Street 2:AGAPE SENIOR PRIAMARY CARE, INC., DBA AGAPE PHYSICIANS
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201
Mailing Address - Country:US
Mailing Address - Phone:803-454-0365
Mailing Address - Fax:803-404-6000
Practice Address - Street 1:4711 SUNSET BLVD
Practice Address - Street 2:AGAPE PHYSICIANS CARE
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-9151
Practice Address - Country:US
Practice Address - Phone:803-356-3609
Practice Address - Fax:803-451-6135
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC07472207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC74724Medicaid
SC74724Medicaid
SCB916576183Medicare PIN
SC6661Medicare PIN