Basic Information
| Provider Information | |||||||||
| NPI: | 1043277437 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER INTEGRATED MEDICAL ASSOCIATES, LTD | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PRIMED PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 MERCHANT ST | ||||||||
| Address2: | STE 220 - ATTN CREDENTIALING | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452463740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135331199 | ||||||||
| FaxNumber: | 5136459827 | ||||||||
| Practice Location | |||||||||
| Address1: | 540 LINCOLN PARK BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454296401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372988058 | ||||||||
| FaxNumber: | 9372985638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 04/26/2019 | ||||||||
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| AuthorizedOfficialLastName: | COUCH | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9378983600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 3005198 | 05 | OH | MEDICAID |