Provider Demographics
NPI:1063570224
Name:PENCHUK, STEPHANIE JO (PHYSICIAN)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:JO
Last Name:PENCHUK
Suffix:
Gender:F
Credentials:PHYSICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 SANDERSON RD STE 202
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02917
Mailing Address - Country:US
Mailing Address - Phone:401-231-3138
Mailing Address - Fax:401-231-4757
Practice Address - Street 1:41 SANDERSON RD STE 202
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:RI
Practice Address - Zip Code:02917-2603
Practice Address - Country:US
Practice Address - Phone:401-231-3138
Practice Address - Fax:401-231-4757
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD08739208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA73004OtherSTATE LICENCE
RISP40427Medicaid
RIMD08739OtherSTATE LICENSE
RIMD08739OtherSTATE LICENSE
RIMD08739OtherSTATE LICENSE
F91955Medicare UPIN