Provider Demographics
NPI:1033625983
Name:PREMIERE MEDICAL LLC
Entity Type:Organization
Organization Name:PREMIERE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TSOGBE
Authorized Official - Suffix:
Authorized Official - Credentials:APNP
Authorized Official - Phone:301-908-9136
Mailing Address - Street 1:PO BOX 639
Mailing Address - Street 2:
Mailing Address - City:THIENSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53092-0639
Mailing Address - Country:US
Mailing Address - Phone:414-247-9005
Mailing Address - Fax:414-247-9004
Practice Address - Street 1:6877 N SEVILLE AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-2645
Practice Address - Country:US
Practice Address - Phone:414-247-9005
Practice Address - Fax:414-247-9004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-14
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4763261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care