Provider Demographics
NPI:1356399604
Name:PENNEBAKER, RICHARD SIDDALL (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:SIDDALL
Last Name:PENNEBAKER
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:ONE INDEPENDENCE POINTE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4566
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:864-797-6198
Practice Address - Street 1:57 CROSS PARK COURT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4264
Practice Address - Country:US
Practice Address - Phone:864-797-6044
Practice Address - Fax:864-797-6198
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12799208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTL5018Medicaid
SCB918277951Medicare PIN
SCB918273640Medicare PIN
SC370005488Medicare PIN
SCTL5018Medicaid
SCB918273365Medicare PIN