Basic Information
| Provider Information | |||||||||
| NPI: | 1053877506 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER MED PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7512 DR PHILLIPS BLVD STE 50-344 | ||||||||
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| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328195420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075436306 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2906 17TH ST. | ||||||||
| Address2: | |||||||||
| City: | ST CLOUD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075436306 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2019 | ||||||||
| LastUpdateDate: | 10/18/2019 | ||||||||
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| AuthorizedOfficialLastName: | AYADI | ||||||||
| AuthorizedOfficialFirstName: | JAUVID | ||||||||
| AuthorizedOfficialMiddleName: | BEHRAM | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4073522542 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 208M00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.