Basic Information
| Provider Information | |||||||||
| NPI: | 1942483433 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER PHYSICIANS CENTERS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24500 CENTER RIDGE RD STE 375 | ||||||||
| Address2: | |||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441455631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408955056 | ||||||||
| FaxNumber: | 4403332935 | ||||||||
| Practice Location | |||||||||
| Address1: | 25200 CENTER RIDGE RD | ||||||||
| Address2: | SUITE 3100 | ||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441454141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403314559 | ||||||||
| FaxNumber: | 4403332935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2007 | ||||||||
| LastUpdateDate: | 10/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | FINTZ | ||||||||
| AuthorizedOfficialFirstName: | DICK | ||||||||
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| AuthorizedOfficialTitleorPosition: | INTERIUM CEO | ||||||||
| AuthorizedOfficialTelephone: | 4408955056 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PREMIER PHYSICIANS CENTERS, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 10/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 0791AS | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 2040482 | 05 | OH | MEDICAID | 490003414 | 01 | RAILROAD MEDICARE GROUP # | OTHER | 1942483433 | 01 | ASC NPI GROUP # | OTHER | D368301 | 01 | GROUP IND DIAGNOSTICS LAB | OTHER | 4511 | 01 | GROUP RR MEDICARE | OTHER | 3610861 | 01 | ASC GROUP MEDICARE # | OTHER |