1518096239 NPI number — PREMIER ORTHOPEDICS, P.A.

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 1518096239 NPI number — PREMIER ORTHOPEDICS, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER ORTHOPEDICS, P.A.
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:
1518096239
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3570 SAINT JOHNS 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:
21042-4020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-461-9500
Provider Business Mailing Address Fax Number:
410-461-8945

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
545 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 217
Provider Business Practice Location Address City Name:
LAUREL
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20707-4351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-776-2000
Provider Business Practice Location Address Fax Number:
301-776-2806
Provider Enumeration Date:
03/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BUSCH
Authorized Official First Name:
MYRA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE GROUP COORDINATOR
Authorized Official Telephone Number:
410-461-9500

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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