Basic Information
| Provider Information | |||||||||
| NPI: | 1275522864 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMIER FAMILY CARE I, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PREMIER PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5426 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049155400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4326866600 | ||||||||
| FaxNumber: | 4326822284 | ||||||||
| Practice Location | |||||||||
| Address1: | 4214 ANDREWS HWY STE 240 | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797034817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4326866605 | ||||||||
| FaxNumber: | 4326822284 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2005 | ||||||||
| LastUpdateDate: | 02/24/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WYNNE | ||||||||
| AuthorizedOfficialFirstName: | CANDACE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 4326866605 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 207N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207ND0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 2080A0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 208200000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 208VP0014X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 261QR0404X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Cardiac Facilities | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 079837301 | 05 | TX | MEDICAID | 0008AH | 01 | TX | BCBS | OTHER | 018061401 | 01 | TX | MEDICAID EPSDT | OTHER |