Provider Demographics
NPI:1568541480
Name:PERNA, SAMUEL
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:PERNA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 6TH AVE S
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35233-1801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1717 6TH AVE S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1801
Practice Address - Country:US
Practice Address - Phone:800-822-8816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL966207QH0002X
ALDO966207QH0002X, 2080H0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No2080H0002XAllopathic & Osteopathic PhysiciansPediatricsHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009912898Medicaid
AL051545714OtherBCBS
AL051545732OtherBCBS
AL051545734OtherBCBS
MS02556099Medicaid
AL009912893Medicaid
AL009912894Medicaid
AL009912896Medicaid
AL102I083878Medicare PIN
AL051545731Medicare PIN