MEDICARE: MR. SAMUEL PERENICH PA

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	363A00000X	Physician Assistant	PA9119155	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MA067383	OTHER	PA	LICENSE
2	PA9119155	OTHER	FL	STATE LICENSE

General Provider Information

NPI Number	:	1467270009
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SAMUEL PERENICH PA

Provider Business Mailing Address
First Line	:	151 SOUTHHALL LN STE 300
Second Line	:
City	:	MAITLAND
State	:	FL
Zip	:	32751-7172
Country	:	US
Telephone Number	:	570-454-7546
Fax Number	:

Provider Business Practice Location Address
First Line	:	631 AIRPORT RD STE 100
Second Line	:
City	:	HAZLE TOWNSHIP
State	:	PA
Zip	:	18202-3379
Country	:	US
Telephone Number	:	570-454-7546
Fax Number	:	570-455-7547

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

Provider Enumeration Date	:	10/02/2024
Last Update Date	:	12/03/2025

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Directions to “ MR. SAMUEL PERENICH PA” Practice Location

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