Basic Information
| Provider Information | |||||||||
| NPI: | 1356399489 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER INTEGRATED MEDICAL ASSOC. LTD. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PRIMED PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 SMITH RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452122787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136196819 | ||||||||
| FaxNumber: | 5136452393 | ||||||||
| Practice Location | |||||||||
| Address1: | 540 LINCOLN PARK BLVD | ||||||||
| Address2: | SUITE350 | ||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454296401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373128100 | ||||||||
| FaxNumber: | 9373128101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 12/31/2009 | ||||||||
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| AuthorizedOfficialLastName: | COUCH | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9378983600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2512669 | 05 | OH | MEDICAID |