Provider Demographics
NPI:1447226253
Name:KERRY PENNINGTON, PA
Entity Type:Organization
Organization Name:KERRY PENNINGTON, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:F
Authorized Official - Last Name:PENNINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-226-6754
Mailing Address - Street 1:1012 E CHURCH ST
Mailing Address - Street 2:SUTIE A
Mailing Address - City:WARREN
Mailing Address - State:AR
Mailing Address - Zip Code:71671-3509
Mailing Address - Country:US
Mailing Address - Phone:870-226-6754
Mailing Address - Fax:870-226-7925
Practice Address - Street 1:1012 E CHURCH ST
Practice Address - Street 2:SUTIE A
Practice Address - City:WARREN
Practice Address - State:AR
Practice Address - Zip Code:71671-3509
Practice Address - Country:US
Practice Address - Phone:870-226-6754
Practice Address - Fax:870-226-7925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC5438207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR110722002Medicaid
AR5B909OtherBCBS PROVIDER #
AR133563762Medicaid
AR5B909OtherBCBS PROVIDER #
ARDA7854Medicare PIN