Provider Demographics
NPI:1760813034
Name:E. EARL PENNINGTON, MD, LLC
Entity Type:Organization
Organization Name:E. EARL PENNINGTON, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:PENNINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-954-8538
Mailing Address - Street 1:3890 JOHNS CREEK PKWY
Mailing Address - Street 2:SUITE 360
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-1284
Mailing Address - Country:US
Mailing Address - Phone:678-954-8538
Mailing Address - Fax:770-244-9204
Practice Address - Street 1:3890 JOHNS CREEK PKWY
Practice Address - Street 2:SUITE 360
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-1284
Practice Address - Country:US
Practice Address - Phone:678-954-8538
Practice Address - Fax:770-244-9204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-11
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA015299208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00098084BMedicaid