=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124524038
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMUEL PENNELLA JR. MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2018
-----------------------------------------------------
Last Update Date | 08/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1905 N SHERMAN ST STE 200
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80203-1132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-208-8926
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14 GLENNON FARM LN
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08833-4504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-208-8926
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 68449
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | TW00059
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 4301510893
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | TPME2986
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | DR.0074417
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------