Provider Demographics
NPI:1669589594
Name:PENNINGTON, CHARLES ROYCE (MD)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:ROYCE
Last Name:PENNINGTON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:CHARLES
Other - Middle Name:R
Other - Last Name:PENNINGTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 444
Mailing Address - Street 2:
Mailing Address - City:DILLARD
Mailing Address - State:GA
Mailing Address - Zip Code:30537-0444
Mailing Address - Country:US
Mailing Address - Phone:706-746-6571
Mailing Address - Fax:706-746-5643
Practice Address - Street 1:92 BETTYS CREEK RD
Practice Address - Street 2:
Practice Address - City:DILLARD
Practice Address - State:GA
Practice Address - Zip Code:30537-2257
Practice Address - Country:US
Practice Address - Phone:706-746-6571
Practice Address - Fax:706-746-5643
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025380207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000273831GMedicaid
GA000649822AMedicaid
GA1134316219OtherR H FACILITY
GAD30442Medicare UPIN
GA511G700687Medicare PIN