Provider Demographics
NPI:1366484693
Name:MICHELE PENNINGTON MD FAMILY MEDICAL PLLC
Entity type:Organization
Organization Name:MICHELE PENNINGTON MD FAMILY MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:PENNINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-304-9400
Mailing Address - Street 1:#6620 6620 RELIABLE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0001
Mailing Address - Country:US
Mailing Address - Phone:248-304-9400
Mailing Address - Fax:248-304-9401
Practice Address - Street 1:25775 W 10 MILE RD
Practice Address - Street 2:SUITE B
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-4856
Practice Address - Country:US
Practice Address - Phone:248-304-9400
Practice Address - Fax:248-304-9401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070192207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0801975377OtherRAILROAD MEDICARE
MI0806346602OtherBCBC BCN
MI0N67500Medicare PIN
MI0806346602OtherBCBC BCN