Basic Information
| Provider Information | |||||||||
| NPI: | 1760753180 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER HEALTH SPECIALIST, INC | ||||||||
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| OtherOrganizationName: | PREMIER GYNECOLOGIC ONCOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 WYOMING ST | ||||||||
| Address2: | BERRY BLDG, GROUND FLOOR, STE B | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454092722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372088301 | ||||||||
| FaxNumber: | 9372082014 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 WYOMING ST | ||||||||
| Address2: | BERRY BLDG, GROUND FL, STE B | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454092722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372082901 | ||||||||
| FaxNumber: | 9372082014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2012 | ||||||||
| LastUpdateDate: | 11/07/2013 | ||||||||
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| AuthorizedOfficialLastName: | DANIS | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT / CEO | ||||||||
| AuthorizedOfficialTelephone: | 9374998866 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0201X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
ID Information
| ID | Type | State | Issuer | Description | 0081671 | 05 | OH | MEDICAID |