Basic Information
| Provider Information | |||||||||
| NPI: | 1700887825 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERNIA | ||||||||
| FirstName: | MARIANNA | ||||||||
| MiddleName: | HP | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 620 MADISON STREET | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132102319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154267680 | ||||||||
| FaxNumber: | 3154267798 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 MADISON STREET | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132102319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154267680 | ||||||||
| FaxNumber: | 3154267798 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 07/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 253867 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200400944 | 01 | NC | LICENSE | OTHER | 253876 | 01 | NY | MEDICAL LICENSE | OTHER | 03674191 | 05 | NY | MEDICAID |