Provider Demographics
NPI:1114108172
Name:PENA-SAMPER MEDICAL ASSOCIATES, INC
Entity Type:Organization
Organization Name:PENA-SAMPER MEDICAL ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:MARCELA
Authorized Official - Last Name:PENA-PERILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-935-6334
Mailing Address - Street 1:7820 N ARMENIA AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33604-3852
Mailing Address - Country:US
Mailing Address - Phone:813-935-6334
Mailing Address - Fax:813-935-5237
Practice Address - Street 1:7820 N ARMENIA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-3852
Practice Address - Country:US
Practice Address - Phone:813-935-6334
Practice Address - Fax:813-935-5237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME38971207R00000X
FLME51328207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME51328OtherFL LICENSE
FLME38971OtherFL LICENSE
FL064723300Medicaid