Basic Information
| Provider Information | |||||||||
| NPI: | 1750358099 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PERNI | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24740 ENERGY HWY | ||||||||
| Address2: | |||||||||
| City: | NEW MARTINSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261558570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126591544 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15100 RESCUE WAY | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337623502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275351437 | ||||||||
| FaxNumber: | 7275354190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 05/01/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | OS008592L | PA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 101436352 | 05 | PA | MEDICAID |