Provider Demographics
NPI:1932253002
Name:PENN MEDICAL GROUP, P.C.
Entity Type:Organization
Organization Name:PENN MEDICAL GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:BADDICK
Authorized Official - Suffix:III
Authorized Official - Credentials:DO
Authorized Official - Phone:570-386-4171
Mailing Address - Street 1:780 N KROCKS RD STE 101A
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18106-9075
Mailing Address - Country:US
Mailing Address - Phone:610-365-3354
Mailing Address - Fax:610-365-3361
Practice Address - Street 1:780 N KROCKS RD STE 101A
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18106-9075
Practice Address - Country:US
Practice Address - Phone:610-365-3354
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1215993928OtherDR. BADDICK NPI
PA0015989840002Medicaid
PA0019475840006Medicaid
PA1629038468OtherDR. OGBOLU NPI
PA1629038468OtherDR. OGBOLU NPI
PAH79296Medicare UPIN
PA885601N4YMedicare ID - Type UnspecifiedDR. BADDICK MEDICARE
PA0015989840002Medicaid