Provider Demographics
NPI:1043277437
Name:PREMIER INTEGRATED MEDICAL ASSOCIATES, LTD
Entity Type:Organization
Organization Name:PREMIER INTEGRATED MEDICAL ASSOCIATES, LTD
Other - Org Name:PRIMED PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:COUCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-898-3600
Mailing Address - Street 1:25 MERCHANT ST
Mailing Address - Street 2:STE 220 - ATTN CREDENTIALING
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-3740
Mailing Address - Country:US
Mailing Address - Phone:513-533-1199
Mailing Address - Fax:513-645-9827
Practice Address - Street 1:540 LINCOLN PARK BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-6401
Practice Address - Country:US
Practice Address - Phone:937-298-8058
Practice Address - Fax:937-298-5638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3005198Medicaid
CA2478Medicare PIN
IN237680Medicare PIN
OH3005198Medicaid