Provider Demographics
NPI:1780873547
Name:ROBERT ELDEN PENNINGTON MD, PHD, PC
Entity type:Organization
Organization Name:ROBERT ELDEN PENNINGTON MD, PHD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PENNINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:505-625-5512
Mailing Address - Street 1:1 EL ARCO IRIS DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-7711
Mailing Address - Country:US
Mailing Address - Phone:505-625-5512
Mailing Address - Fax:505-625-1013
Practice Address - Street 1:1 EL ARCO IRIS DR
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-7711
Practice Address - Country:US
Practice Address - Phone:505-625-5512
Practice Address - Fax:505-625-1013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM95321208VP0000X, 204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM72080Medicaid