Basic Information
| Provider Information | |||||||||
| NPI: | 1740242957 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMIER MEDICAL GROUP PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PMEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3799 | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370433799 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9312457000 | ||||||||
| FaxNumber: | 9312457069 | ||||||||
| Practice Location | |||||||||
| Address1: | 490 DUNLOP LN | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370405007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9312457000 | ||||||||
| FaxNumber: | 9312457069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 01/18/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LIVERETT | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9312457000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | CA4837 | 01 | TN | RR MEDICARE | OTHER | 3164217 | 01 | TN | BCBS GROUP # | OTHER | 117241 | 01 | TN | AETNA GROUP # | OTHER |