Healthcare Provider Details

I. General information

NPI: 1124524038
Provider Name (Legal Business Name): SAMUEL PENNELLA JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 SHELBY ST STE 700
DETROIT MI
48226-3282
US

IV. Provider business mailing address

14 GLENNON FARM LN
LEBANON NJ
08833-4504
US

V. Phone/Fax

Practice location:
  • Phone: 908-208-8926
  • Fax:
Mailing address:
  • Phone: 908-208-8926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number68449
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberTW00059
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberTPME2986
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberDR.0074417
License Number StateCO
# 5
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4301510893
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: