MEDICARE: DR. SAMUEL PENNELLA JR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	68449	MN
2	208D00000X	General Practice Physician	TW00059	KS
3	208D00000X	General Practice Physician	TPME2986	FL
4	208D00000X	General Practice Physician	DR.0074417	CO
5	208D00000X	General Practice Physician	4301510893	MI

General Provider Information

NPI Number	:	1124524038
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAMUEL PENNELLA JR. MD

Provider Business Mailing Address
First Line	:	14 GLENNON FARM LN
Second Line	:
City	:	LEBANON
State	:	NJ
Zip	:	08833-4504
Country	:	US
Telephone Number	:	908-208-8926
Fax Number	:

Provider Business Practice Location Address
First Line	:	607 SHELBY ST STE 700
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48226-3282
Country	:	US
Telephone Number	:	908-208-8926
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2018
Last Update Date	:	05/06/2026

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