Provider Demographics
NPI:1427303015
Name:ELIZABETH L PENN MD PC
Entity type:Organization
Organization Name:ELIZABETH L PENN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:PENN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-871-5437
Mailing Address - Street 1:16741 GA HIGHWAY 67
Mailing Address - Street 2:STE F
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-2528
Mailing Address - Country:US
Mailing Address - Phone:912-871-5437
Mailing Address - Fax:912-681-6551
Practice Address - Street 1:16741 GA HIGHWAY 67
Practice Address - Street 2:STE F
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-2528
Practice Address - Country:US
Practice Address - Phone:912-871-5437
Practice Address - Fax:912-681-6551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA067374208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty