Provider Demographics
NPI:1053474163
Name:PENN, EDWARD BENJAMIN JR (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:BENJAMIN
Last Name:PENN
Suffix:JR
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:200 PATEWOOD DR STE B400
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-6306
Practice Address - Country:US
Practice Address - Phone:864-522-8603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC51723207YP0228X, 207YP0228X
KS9406640207Y00000X
TNMD48783207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology