Basic Information
| Provider Information | |||||||||
| NPI: | 1114213055 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMIER HEALTH SPECIALISTS INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COMPREHENSIVE BURN AND WOUND SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 WYOMING ST | ||||||||
| Address2: | SUITE 3272 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454092722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372086790 | ||||||||
| FaxNumber: | 9372086797 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 WYOMING ST | ||||||||
| Address2: | SUITE 3272 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454092722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372086790 | ||||||||
| FaxNumber: | 9372086797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2011 | ||||||||
| LastUpdateDate: | 12/26/2013 | ||||||||
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| AuthorizedOfficialLastName: | DANIS | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 9374354263 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PREMIER HEALTH SPECIALISTS INC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0052094 | 05 | OH | MEDICAID |