Basic Information
| Provider Information | |||||||||
| NPI: | 1790749307 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER INTEGRATED MEDICAL ASSOCIATES, LTD | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PRIMED NORTHWEST DAYTON PEDS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 MERCHANT ST | ||||||||
| Address2: | STE. 220 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452463700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135336507 | ||||||||
| FaxNumber: | 5136459767 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 W WENGER RD | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453222762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9378369921 | ||||||||
| FaxNumber: | 9378361298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2006 | ||||||||
| LastUpdateDate: | 03/11/2016 | ||||||||
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| AuthorizedOfficialLastName: | MOLFENTER | ||||||||
| AuthorizedOfficialFirstName: | GERALD | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9378369921 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 2080948 | 05 | OH | MEDICAID |