Provider Demographics
NPI:1316038920
Name:PENSCOTT MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PENSCOTT MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-736-8510
Mailing Address - Street 1:4165 BLACKHAWK PLAZA CIR
Mailing Address - Street 2:#250
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94506-4904
Mailing Address - Country:US
Mailing Address - Phone:925-736-8510
Mailing Address - Fax:925-736-2491
Practice Address - Street 1:4165 BLACKHAWK PLAZA CIR
Practice Address - Street 2:#250
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94506-4904
Practice Address - Country:US
Practice Address - Phone:925-736-8510
Practice Address - Fax:925-736-2491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53582207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ17563ZMedicare ID - Type Unspecified
CAZZZ28370ZMedicare ID - Type Unspecified