Provider Demographics
NPI:1093142895
Name:PREMIER MEDICAL ALLIANCE LLC
Entity Type:Organization
Organization Name:PREMIER MEDICAL ALLIANCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:AVEZZANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-967-8221
Mailing Address - Street 1:466 OLD HOOK ROAD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:EMERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07630-1368
Mailing Address - Country:US
Mailing Address - Phone:201-967-8221
Mailing Address - Fax:201-634-9647
Practice Address - Street 1:466 OLD HOOK ROAD
Practice Address - Street 2:SUITE 1
Practice Address - City:EMERSON
Practice Address - State:NJ
Practice Address - Zip Code:07630-1368
Practice Address - Country:US
Practice Address - Phone:201-967-8221
Practice Address - Fax:201-634-9647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-11
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA0806440207K00000X
NJ25MA05477400207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty