Basic Information
| Provider Information | |||||||||
| NPI: | 1801300314 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER PHYSICIANS CENTERS, INC. | ||||||||
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| 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: | 805 COLUMBIA RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441451461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162272194 | ||||||||
| FaxNumber: | 2162272196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2017 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | DYBIEC | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4408955036 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 |