Basic Information
| Provider Information | |||||||||
| NPI: | 1184092520 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMIER FAMILY PRACTICE OF PENNSYLVANIA LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PREMIER CLINIC LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 278 EAGLEVIEW BLVD | ||||||||
| Address2: | |||||||||
| City: | EXTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193411157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105616400 | ||||||||
| FaxNumber: | 6105616401 | ||||||||
| Practice Location | |||||||||
| Address1: | 2385 W CHELTENHAM AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191501506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105616400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2015 | ||||||||
| LastUpdateDate: | 09/02/2015 | ||||||||
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| AuthorizedOfficialLastName: | SILVERMAN | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6102470891 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.