1306105655 NPI number — PREMIER MEDICAL ASSOCIATES, LLC

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 1306105655 NPI number — PREMIER MEDICAL ASSOCIATES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER MEDICAL ASSOCIATES, LLC
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:
1306105655
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4050 HEALTHWAY DR
Provider Second Line Business Mailing Address:
SUITE 140
Provider Business Mailing Address City Name:
AURORA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60504-8183
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-318-3355
Provider Business Mailing Address Fax Number:
630-701-9277

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4050 HEALTHWAY DR
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
AURORA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60504-8183
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-318-3355
Provider Business Practice Location Address Fax Number:
630-701-9277
Provider Enumeration Date:
05/07/2012

Additional Information

Authorized Official

Authorized Official Last Name:
RUPP
Authorized Official First Name:
ALICE
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
630-318-3355

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  209006778 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 00303608379601 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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