Provider Demographics
NPI:1841254653
Name:JENNIFER W PENNOYER MD LLC
Entity type:Organization
Organization Name:JENNIFER W PENNOYER MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:WHITE
Authorized Official - Last Name:PENNOYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-243-3020
Mailing Address - Street 1:701 COTTAGE GROVE ROAD
Mailing Address - Street 2:E110
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002
Mailing Address - Country:US
Mailing Address - Phone:860-243-3020
Mailing Address - Fax:860-243-3002
Practice Address - Street 1:701 COTTAGE GROVE ROAD
Practice Address - Street 2:E110
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002
Practice Address - Country:US
Practice Address - Phone:860-243-3020
Practice Address - Fax:860-243-3002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03432Medicare ID - Type Unspecified