Provider Demographics
NPI:1396785424
Name:PENNINGTON, BRUCE L (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:L
Last Name:PENNINGTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-446-5289
Mailing Address - Fax:740-446-5697
Practice Address - Street 1:100 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1560
Practice Address - Country:US
Practice Address - Phone:740-446-5289
Practice Address - Fax:740-446-5697
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV166942085R0202X
OH35-06-02472085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0118365000Medicaid
000000007285OtherANTHEM BCBS
OH000000193002OtherUNISON MEDICAID
001714061OtherMOUNTAIN STATE BCBS
OH0798650OtherMOLINA MEDICAID
300028175OtherRR MEDICARE
OH0798650OtherMOLINA MEDICAID
WV0118365000Medicaid
OH0672574Medicare PIN
WV0672573Medicare PIN