Provider Demographics
NPI:1891784724
Name:PENNEBACKER, PAIGE KOENIG (MD)
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:KOENIG
Last Name:PENNEBACKER
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 14731
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34280-4731
Mailing Address - Country:US
Mailing Address - Phone:941-761-0500
Mailing Address - Fax:941-761-0400
Practice Address - Street 1:315 75TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-3201
Practice Address - Country:US
Practice Address - Phone:941-761-0500
Practice Address - Fax:855-521-2857
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62365208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL17698ZMedicare ID - Type Unspecified
FLE76326Medicare UPIN