1366956625 NPI number — PREMIER PHYSICIAN PARTNERS PC

Table of content: (NPI 1366956625)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366956625 NPI number — PREMIER PHYSICIAN PARTNERS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER PHYSICIAN PARTNERS PC
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:
1366956625
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/24/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5859 DONOVAN LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELLICOTT CITY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21043-6903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5859 DONOVAN LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELLICOTT CITY
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21043-6903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-282-1796
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/24/2017

Additional Information

Authorized Official

Authorized Official Last Name:
KHAN
Authorized Official First Name:
ADNAN
Authorized Official Middle Name:
RAHMAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
703-282-1796

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  D58291 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207ZC0006X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZC0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZD0900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZH0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZM0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZN0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0007X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0105X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0213X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 13721023 . This is a "CAQH PROVIDER ID" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 12542361 . This is a "CAQH PROVIDER ID" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 10416554 . This is a "CAQH PROVIDER ID" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 12780303 . This is a "CAQH PROVIDER ID" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 10436137 . This is a "CAQH PROVIDER ID" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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