Basic Information
Provider Information | |||||||||
NPI: | 1912907114 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PREMIER FAMILY MEDICINE ASSOCIATES, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PVHC AT POMONA | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1770 N ORANGE GROVE AVE STE 101 | ||||||||
Address2: |   | ||||||||
City: | POMONA | ||||||||
State: | CA | ||||||||
PostalCode: | 917673027 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9094699494 | ||||||||
FaxNumber: | 9094692120 | ||||||||
Practice Location | |||||||||
Address1: | 1770 N ORANGE GROVE AVE STE 101 | ||||||||
Address2: |   | ||||||||
City: | POMONA | ||||||||
State: | CA | ||||||||
PostalCode: | 917673027 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9094699494 | ||||||||
FaxNumber: | 9094692120 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/28/2005 | ||||||||
LastUpdateDate: | 07/15/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BEGOVIC | ||||||||
AuthorizedOfficialFirstName: | SNEZANA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9094699494 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PREMIER FAMILY MEDICINE ASSOCIATES,INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 07/15/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 261QH0100X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
ID Information
ID | Type | State | Issuer | Description | 1912907114 | 05 | CA |   | MEDICAID | GR0083730 | 05 | CA |   | MEDICAID | 00127095 | 01 | CA | POMONA BUSINESS LICENSE | OTHER | CG8716 | 01 |   | RAILROAD MEDICARE | OTHER | ZZZ57392Z | 01 |   | BLUE SHIELD OF CALIFORNIA | OTHER | 05D0931230 | 01 | CA | CLIA | OTHER |