Provider Demographics
NPI:1366441552
Name:PENNIMAN, WRIGHT C (DO)
Entity Type:Individual
Prefix:DR
First Name:WRIGHT
Middle Name:C
Last Name:PENNIMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 ADDISON DR
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29730-8097
Mailing Address - Country:US
Mailing Address - Phone:803-329-1930
Mailing Address - Fax:803-328-2549
Practice Address - Street 1:3601 SW 160TH AVE
Practice Address - Street 2:SUITE250
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-6308
Practice Address - Country:US
Practice Address - Phone:877-866-7123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC00663207Q00000X
FLOS 12653207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC006638Medicaid
SCH25168(7180)(7366)Medicare ID - Type Unspecified
SC080192651Medicare PIN
SC080192652Medicare PIN
SCH251687180Medicare PIN
H25168Medicare UPIN
SCH251687366Medicare PIN