Active NPI
Richard Siddall Pennebaker, M.D.
- Pediatrics Physician
- Greenville, SC
National Provider Identifier
1356399604
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatrics Physician
- License
- 12799
- Practice address
- 57 Cross Park Court
Greenville, SC 29605-4264 - Phone
- (864) 797-6044
- Fax
- (864) 797-6198
- NPI assigned
- May 5, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician | 208000000X | 12799 | SC | Primary |
Addresses
Primary practice location
57 Cross Park Court
Greenville, SC 29605-4264
Mailing address
One Independence Pointe
Suite 212
Greenville, SC 29615-4566
Phone (864) 797-6044
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| TL5018 | Medicaid | SC |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 12799 | SC | MD | Social Worker |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Greenville Health System | Past | Accepting new patients | |
| Greenville Proaxis Therapy, LLC | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- General Acute Care Hospital
- Simpsonville, SC
- NPI 1679992838
-
- Physical Therapist
- Greenville, SC
- NPI 1669457859
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1146787200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1315958400000",
"number": "1356399604",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "ONE INDEPENDENCE POINTE",
"address_2": "SUITE 212",
"city": "GREENVILLE",
"state": "SC",
"postal_code": "296154566",
"telephone_number": "864-797-6044",
"fax_number": "864-797-6198"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "57 CROSS PARK COURT",
"city": "GREENVILLE",
"state": "SC",
"postal_code": "296054264",
"telephone_number": "864-797-6044",
"fax_number": "864-797-6198"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PENNEBAKER",
"first_name": "RICHARD",
"middle_name": "SIDDALL",
"name_prefix": "Dr.",
"credential": "M.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-05-05",
"last_updated": "2011-09-14",
"status": "A"
},
"taxonomies": [
{
"code": "208000000X",
"taxonomy_group": "",
"desc": "Pediatrics",
"state": "SC",
"license": "12799",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "TL5018",
"state": "SC"
}
],
"endpoints": [],
"other_names": []
}Other providers in Greenville, SC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 14, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.