Basic Information
| Provider Information | |||||||||
| NPI: | 1922287317 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER COMPREHENSIVE MANAGEMENT SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 74169 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441944169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408955056 | ||||||||
| FaxNumber: | 4403332935 | ||||||||
| Practice Location | |||||||||
| Address1: | 20525 CENTER RIDGE RD | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | ROCKY RIVER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441163437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408955056 | ||||||||
| FaxNumber: | 4403332935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2007 | ||||||||
| LastUpdateDate: | 02/16/2010 | ||||||||
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| AuthorizedOfficialLastName: | WIEDT | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4408955056 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2916152 | 05 | OH | MEDICAID |