Provider Demographics
NPI:1366494197
Name:PENNEBAKER, GORDON E (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:E
Last Name:PENNEBAKER
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:PO BOX 1259
Mailing Address - Street 2:SENTINEL HEALTH PARTNERS PA BUSINESS OFFICE
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29021-1259
Mailing Address - Country:US
Mailing Address - Phone:803-713-8350
Mailing Address - Fax:803-713-8433
Practice Address - Street 1:1344 HAILE ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020-3076
Practice Address - Country:US
Practice Address - Phone:803-432-1996
Practice Address - Fax:803-424-2703
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18265207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC080181551OtherRAILROAD MEDICARE PIN
B5656OtherMEDCOST
SC182652Medicaid
SC182652Medicaid
B5656OtherMEDCOST