1235483306 NPI number — PREMIER PHYSICIANS OF NEW YORK PLLC

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 1235483306 NPI number — PREMIER PHYSICIANS OF NEW YORK PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER PHYSICIANS OF NEW YORK PLLC
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:
1235483306
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3599 UNIVERSITY BLVD S
Provider Second Line Business Mailing Address:
SUITE 805
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32216-4252
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-309-8680
Provider Business Mailing Address Fax Number:
904-345-5841

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1120 PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10128-1242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-996-6660
Provider Business Practice Location Address Fax Number:
212-996-2506
Provider Enumeration Date:
10/29/2012

Additional Information

Authorized Official

Authorized Official Last Name:
TERK
Authorized Official First Name:
MITCHELL
Authorized Official Middle Name:
D
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
904-309-8680

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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