1073552329 NPI number — PREMIER PHYSICIANS CENTERS, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073552329 NPI number — PREMIER PHYSICIANS CENTERS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER PHYSICIANS CENTERS, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073552329
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20525 CENTER RIDGE RD
Provider Second Line Business Mailing Address:
SUITE 220
Provider Business Mailing Address City Name:
ROCKY RIVER
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44116-3437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-895-5021
Provider Business Mailing Address Fax Number:
440-895-5050

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14600 DETROIT AVE
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44107-4207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-227-0717
Provider Business Practice Location Address Fax Number:
216-227-0827
Provider Enumeration Date:
06/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WIEDT
Authorized Official First Name:
MARK
Authorized Official Middle Name:
E
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
440-895-5021

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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