Provider Demographics
NPI:1144247099
Name:PENNINGTON, AMANDA MARIE (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:PENNINGTON
Suffix:
Gender:F
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:PO BOX 602120
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2120
Mailing Address - Country:US
Mailing Address - Phone:803-329-5131
Mailing Address - Fax:803-366-6600
Practice Address - Street 1:1656 RIVERCHASE BLVD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1724
Practice Address - Country:US
Practice Address - Phone:803-329-5131
Practice Address - Fax:803-366-6600
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20333207Q00000X
NC9300562207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC66763OtherBLUE CROSS BLUE SHIELD NC
080152242OtherRAILROAD MEDICARE
NC1144247099Medicaid
SC203336Medicaid
NC8966763Medicaid
SC203336Medicaid
SCF853824592Medicare PIN
F85382Medicare UPIN