Basic Information
Provider Information | |||||||||
NPI: | 1316291487 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PREMIER PHYSICIANS OF NEW YORK PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3599 UNIVERSITY BLVD S | ||||||||
Address2: | SUITE 805 | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322164252 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9043098680 | ||||||||
FaxNumber: | 9043455841 | ||||||||
Practice Location | |||||||||
Address1: | 12 E 86TH ST | ||||||||
Address2: |   | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100280506 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2125179555 | ||||||||
FaxNumber: | 2127374547 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/29/2012 | ||||||||
LastUpdateDate: | 06/10/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TERK | ||||||||
AuthorizedOfficialFirstName: | MITCHELL | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 9043098680 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X |   | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |   |
No ID Information.