Provider Demographics
NPI:1245254044
Name:WHITE, PENNY LA RUTH (MD)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:LA RUTH
Last Name:WHITE
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 1:3 ERIE CT STE 7140
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2519
Mailing Address - Country:US
Mailing Address - Phone:773-537-0020
Mailing Address - Fax:773-537-0029
Practice Address - Street 1:115 N PARKSIDE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644-3040
Practice Address - Country:US
Practice Address - Phone:773-295-3060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00012637208000000X
IL036122437208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL630904034Medicaid
AL630901034Medicaid
AL630900034Medicaid
AL630902034Medicaid
AL630903034Medicaid
AL630904034Medicaid
AL000027837Medicare ID - Type Unspecified