Provider Demographics
NPI:1003948795
Name:PREMIER ORTHOPAEDICS & SPORTS MEDICINE, PCL
Entity Type:Organization
Organization Name:PREMIER ORTHOPAEDICS & SPORTS MEDICINE, PCL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:FROMKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-494-3071
Mailing Address - Street 1:5651 FRIST BLVD
Mailing Address - Street 2:SUITE 515
Mailing Address - City:HERMITAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37076-2054
Mailing Address - Country:US
Mailing Address - Phone:615-889-3501
Mailing Address - Fax:615-889-3394
Practice Address - Street 1:5651 FRIST BLVD
Practice Address - Street 2:SUITE 515
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-2054
Practice Address - Country:US
Practice Address - Phone:615-889-3501
Practice Address - Fax:615-889-3394
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREMIER ORTHOPAEDICS & SPORTS MEDICINE, PLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-09
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207X00000X, 261QP2000X
TN332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3658307Medicare PIN
TN3707844Medicare PIN
TN3656051Medicare PIN
TN0922510006Medicare NSC