Provider Demographics
NPI:1053314971
Name:PENNER, TIMOTHY M (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:M
Last Name:PENNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:CLAY CENTER
Mailing Address - State:KS
Mailing Address - Zip Code:67432-1564
Mailing Address - Country:US
Mailing Address - Phone:785-632-2181
Mailing Address - Fax:785-632-2309
Practice Address - Street 1:609 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:CLAY CENTER
Practice Address - State:KS
Practice Address - Zip Code:67432-1564
Practice Address - Country:US
Practice Address - Phone:785-632-2181
Practice Address - Fax:785-632-2309
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS21931207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSE44317Medicare UPIN
KS15533Medicare ID - Type Unspecified