Provider Demographics
NPI:1720296411
Name:PENNINGTON, ANDREA J (MD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:J
Last Name:PENNINGTON
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:PO BOX 37648
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-0648
Mailing Address - Country:US
Mailing Address - Phone:313-300-3738
Mailing Address - Fax:313-449-5862
Practice Address - Street 1:25720 SOUTHFIELD RD APT 104
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-1842
Practice Address - Country:US
Practice Address - Phone:313-300-3738
Practice Address - Fax:313-449-5862
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301407512208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
H81003Medicare UPIN
MI2506300241OtherBLUE CROSS BLUE SHIELD
N31180010Medicare ID - Type Unspecified