=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114108172
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PENA-SAMPER MEDICAL ASSOCIATES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2007
-----------------------------------------------------
Last Update Date | 07/21/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7820 N ARMENIA AVE
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33604-3852
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-935-6334
-----------------------------------------------------
Fax | 813-935-5237
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7820 N ARMENIA AVE
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33604-3852
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-935-6334
-----------------------------------------------------
Fax | 813-935-5237
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. KATHERINE MARCELA PENA-PERILLA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 813-935-6334
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME38971
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number | ME51328
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------