Basic Information
| Provider Information | |||||||||
| NPI: | 1285633370 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER IMAGING AND INTERVENTION, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11795 | ||||||||
| Address2: | L-2543 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253391795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668717843 | ||||||||
| FaxNumber: | 6147649147 | ||||||||
| Practice Location | |||||||||
| Address1: | 122 PINNELL ST # 720 | ||||||||
| Address2: | |||||||||
| City: | RIPLEY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 252719101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668717843 | ||||||||
| FaxNumber: | 6147649147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2005 | ||||||||
| LastUpdateDate: | 08/26/2014 | ||||||||
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| AuthorizedOfficialLastName: | YOUNIS | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3043722731 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | DA1551 | 01 | KY | RAILROAD MEDICARE | OTHER | 65939639 | 05 | KY | MEDICAID | 001707565 | 01 | WV | BCBS | OTHER | 2694777 | 05 | OH | MEDICAID | 3810007221 | 05 | WV | MEDICAID | 000000289222 | 01 | KY | BCBS | OTHER | 001906613 | 05 | WV | MEDICAID | 3810003604 | 05 | WV | MEDICAID | 0207230000 | 05 | WV | MEDICAID | 3810002570 | 05 | WV | MEDICAID | 2649683 | 05 | OH | MEDICAID | DA1021 | 01 | WV | RAILROAD MEDICARE | OTHER |