Basic Information
| Provider Information | |||||||||
| NPI: | 1427083534 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER MEDICAL GROUP, PSC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PHYSICIANS AFFILIATED CARE, PSC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1919 | ||||||||
| Address2: | |||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423021919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709262273 | ||||||||
| FaxNumber: | 2709265200 | ||||||||
| Practice Location | |||||||||
| Address1: | 1030 BURLEW BLVD BLDG A | ||||||||
| Address2: | |||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423031735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709262273 | ||||||||
| FaxNumber: | 2706843212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 08/06/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | BOARMAN | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2709262273 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 207RE0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200000370A | 05 | IN | MEDICAID | CC5837 | 01 | KY | RAILROAD MEDICARE | OTHER | 000000057660 | 01 | KY | ANTHEM BC/BS | OTHER | 65903114 | 05 | KY | MEDICAID |