Provider Demographics
NPI:1184603680
Name:PENGILLY, REBECCA L (MD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:PENGILLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 NW ELKS DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3745
Mailing Address - Country:US
Mailing Address - Phone:541-967-8221
Mailing Address - Fax:
Practice Address - Street 1:1705 WAVERLY DR SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-6952
Practice Address - Country:US
Practice Address - Phone:541-967-8221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5123207Q00000X
ORMD182380207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5611360Medicaid
SDS40788Medicare PIN
SDP00001727Medicare PIN
H25692Medicare UPIN