Provider Demographics
NPI:1922080985
Name:LENNINGTON, BERT RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:BERT
Middle Name:RICHARD
Last Name:LENNINGTON
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 1:770 PINE ST STE 290
Mailing Address - Street 2:ATTN: RADIOLOGY DEPARTMENT
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-7516
Mailing Address - Country:US
Mailing Address - Phone:478-743-1458
Mailing Address - Fax:478-755-1332
Practice Address - Street 1:770 PINE ST STE 290
Practice Address - Street 2:ATTN: RADIOLOGY DEPARTMENT
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-7516
Practice Address - Country:US
Practice Address - Phone:478-743-1458
Practice Address - Fax:478-755-1332
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0207642085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000299329GMedicaid
GA30BDLMQMedicare PIN
D30047Medicare UPIN