Provider Demographics
NPI:1750358099
Name:PERNI, MARK (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:PERNI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24740 ENERGY HWY
Mailing Address - Street 2:
Mailing Address - City:NEW MARTINSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26155-8570
Mailing Address - Country:US
Mailing Address - Phone:912-659-1544
Mailing Address - Fax:
Practice Address - Street 1:15100 RESCUE WAY
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33762-3502
Practice Address - Country:US
Practice Address - Phone:727-535-1437
Practice Address - Fax:727-535-4190
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008592L207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101436352Medicaid
F68829Medicare UPIN
PA782042Medicare ID - Type Unspecified