NPIMap

Individual provider Active NPI

Willie A Pennick, MD

  • Family Medicine Physician
  • Jacksonville, FL
National Provider Identifier
1568426302
Registry record updated Jul 2, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
ME53419 Issued in FL
Practice address
1760 Edgewood Ave W
Suite B
Jacksonville, FL 32208-7209
Phone
(904) 358-8480
Fax
(904) 358-8460
NPI assigned
Apr 17, 2006
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jul 2, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X ME53419 FL Primary

Addresses

Primary practice location

1760 Edgewood Ave W
Suite B
Jacksonville, FL 32208-7209

Mailing address

1760 Edgewood Ave W
Suite B
Jacksonville, FL 32208-7209
Phone (904) 358-8480

Other identifiers 1

IdentifierTypeStateIssuer
062977400MedicaidFL

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20050806000017 FL Practitioner - Family Practice 2365471711 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
University of Florida College of Medicine, 1985
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
St Vincent'S Ambulatory Care IncGroup PAC ID 2860411188, 303 clinicians

Practice addresses (Care Compare)

1699 S 14TH St
Fernadina Beach, FL 32034-1964

1760 Edgewood Ave W
Suite Aandb
Jacksonville, FL 32208-7209
Phone (904) 450-6250

1760 W Edgewood Ave
Jacksonville, FL 32208-7209
Phone (904) 358-8480

1801 Barrs St
Suite 120
Jacksonville, FL 32204-4738
Phone (904) 308-2006

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
ME53419FLMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
St Vincent'S Full Service Urgent Care, LLC CurrentSince May 17, 2024 Accepting new patients
St Vincents Ambulatory Care Inc CurrentSince Jul 1, 2014 Accepting new patients
St Vincents Ambulatory Care Inc CurrentSince Jul 1, 2014 Accepting new patients
First Coast Primary Care Inc Family Medicine Past Accepting new patients

Locations

6856 103rd St
Jacksonville, FL 32210
Phone (904) 777-0616

2627 Riverside Ave
Jacksonville, FL 32204
Phone (904) 308-7372

1760 Edgewood Ave W
#B
Jacksonville, FL 32208
Phone (904) 358-8480

1760 Edgewood Ave W
Jacksonville, FL 32208
Phone (904) 253-1030

4205 Belfort Rd
Ste 4015
Jacksonville, FL 32216
Phone (904) 296-5691

9560 Crosshill Blvd
Ste 110
Jacksonville, FL 32222
Phone (904) 203-1296

7963 Normandy Blvd
Jacksonville, FL 32221
Phone (904) 379-1203

6488 103rd St
Ste A
Jacksonville, FL 32210
Phone (904) 450-6800

Interoperability endpoints

  • Direct secure messaging: willie.pennick.2@8967.direct.athenahealth.com
  • Direct secure messaging: willie.pennick.1@8967.direct.athenahealth.com

Organizations & group practices 4

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.

Hospital & facility affiliations 11

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1145232000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1404259200000",
    "number": "1568426302",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1760 EDGEWOOD AVE W",
            "address_2": "SUITE B",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322087209",
            "telephone_number": "904-358-8480",
            "fax_number": "904-358-8460"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1760 EDGEWOOD AVE W",
            "address_2": "SUITE B",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322087209",
            "telephone_number": "904-358-8480",
            "fax_number": "904-358-8460"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PENNICK",
        "first_name": "WILLIE",
        "middle_name": "A",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-04-17",
        "last_updated": "2014-07-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "FL",
            "license": "ME53419",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "062977400",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Jacksonville, FL

Sources for this page

Verify at the official NPI Registry.