Basic Information
Provider Information | |||||||||
NPI: | 1194224170 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PREMIER PHYSICIANS CENTERS INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | REMEDY SLEEP DISORDERS CENTER | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 24651 CENTER RIDGE RD STE 350 | ||||||||
Address2: |   | ||||||||
City: | WESTLAKE | ||||||||
State: | OH | ||||||||
PostalCode: | 441455627 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4408955056 | ||||||||
FaxNumber: | 4408955050 | ||||||||
Practice Location | |||||||||
Address1: | 25761 LORAIN RD FL 2 | ||||||||
Address2: |   | ||||||||
City: | NORTH OLMSTED | ||||||||
State: | OH | ||||||||
PostalCode: | 440703368 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4407344900 | ||||||||
FaxNumber: | 4407344902 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/06/2018 | ||||||||
LastUpdateDate: | 06/16/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DYBIEC | ||||||||
AuthorizedOfficialFirstName: | JEFF | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 4408955036 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PREMIER PHYSICIANS CENTERS INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
ID Information
ID | Type | State | Issuer | Description | 0119204 | 05 | OH |   | MEDICAID |