Provider Demographics
NPI:1568992782
Name:RAFFAELE PENNELLA MD LLC
Entity Type:Organization
Organization Name:RAFFAELE PENNELLA MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFFAELE
Authorized Official - Middle Name:
Authorized Official - Last Name:PENNELLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-889-3332
Mailing Address - Street 1:3808 S. GREYSTONE CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804
Mailing Address - Country:US
Mailing Address - Phone:417-889-3332
Mailing Address - Fax:417-881-1410
Practice Address - Street 1:3808 S GREYSTONE CT
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-6561
Practice Address - Country:US
Practice Address - Phone:417-889-3332
Practice Address - Fax:417-881-1410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110288207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty