Basic Information
Provider Information | |||||||||
NPI: | 1093829442 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PREMIER MEDICAL ASSOCIATES ALL FLORIDA, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PREMIER MEDICAL ASSOCIATES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1580 SANTA BARBARA BLVD | ||||||||
Address2: |   | ||||||||
City: | THE VILLAGES | ||||||||
State: | FL | ||||||||
PostalCode: | 321596827 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3522592159 | ||||||||
FaxNumber: | 3526744386 | ||||||||
Practice Location | |||||||||
Address1: | 1580 SANTA BARBARA BLVD | ||||||||
Address2: | SUITE C | ||||||||
City: | THE VILLAGES | ||||||||
State: | FL | ||||||||
PostalCode: | 32159 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3522592159 | ||||||||
FaxNumber: | 3522595731 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/19/2006 | ||||||||
LastUpdateDate: | 02/07/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROMSKA | ||||||||
AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 3523534212 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/07/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | ARNP3378652 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 207RN0300X | ME95629 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207R00000X | ME0069935 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 004699000 | 05 | FL |   | MEDICAID | K3300 | 01 | FL | PTAN | OTHER |