1043287626 NPI number — PREMIER MEDICAL SERVICES

Table of content: (NPI 1043287626)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043287626 NPI number — PREMIER MEDICAL SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER MEDICAL SERVICES
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:
1043287626
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
327 DAHLONEGA ST STE A603
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CUMMING
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30040-2488
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-781-4138
Provider Business Mailing Address Fax Number:
770-781-2588

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
327 DAHLONEGA ST STE A603
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CUMMING
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30040-2488
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-781-4138
Provider Business Practice Location Address Fax Number:
770-781-2588
Provider Enumeration Date:
03/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CRAFT
Authorized Official First Name:
J.
Authorized Official Middle Name:
DOUGLAS
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
404-767-6400

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 519893850A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 356770 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 459823570A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6690445 . This is a "CIGNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 5931689 . This is a "AETNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 82480 . This is a "NORTHWOODS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 52614526 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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