Provider Demographics
NPI:1548287436
Name:PENOVICH, PATRICIA E (MD)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:E
Last Name:PENOVICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:225 SMITH AVE N
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-2697
Mailing Address - Country:US
Mailing Address - Phone:651-241-5290
Mailing Address - Fax:651-241-5248
Practice Address - Street 1:225 SMITH AVE N
Practice Address - Street 2:SUITE 201
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2697
Practice Address - Country:US
Practice Address - Phone:651-241-5290
Practice Address - Fax:651-241-5248
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2011-04-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN354882084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN893702800Medicaid
A79884Medicare UPIN
MN893702800Medicaid