MEDICARE: DR. MARK NICHOLAS PERENICH D.O.

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	207XS0117X	Orthopaedic Surgery of the Spine Physician	Q3421	TX
2	207XS0117X	Orthopaedic Surgery of the Spine Physician	OS14036	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	VJSQK	OTHER	FL	BLUE CROSS
2	OS14036	OTHER	FL	MEDICAL LICENSE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497060487
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK NICHOLAS PERENICH D.O.

Provider Business Mailing Address
First Line	:	7702 STILL PARK CIR
Second Line	:
City	:	ODESSA
State	:	FL
Zip	:	33556-2263
Country	:	US
Telephone Number	:	813-803-0029
Fax Number	:	813-949-8919

Provider Business Practice Location Address
First Line	:	6536 GUNN HWY.
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33625-3853
Country	:	US
Telephone Number	:	813-803-0029
Fax Number	:	813-949-8919

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

Provider Enumeration Date	:	08/13/2010
Last Update Date	:	03/16/2021

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