Provider Demographics
NPI:1093922072
Name:PREMIER PEDIATRIC GROUP INC.
Entity Type:Organization
Organization Name:PREMIER PEDIATRIC GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-770-3466
Mailing Address - Street 1:PO BOX 635228
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0043
Mailing Address - Country:US
Mailing Address - Phone:513-770-3466
Mailing Address - Fax:513-770-3467
Practice Address - Street 1:5386 COX SMITH ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040
Practice Address - Country:US
Practice Address - Phone:513-770-3466
Practice Address - Fax:513-770-3467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2426771Medicaid
OH7200478OtherAETNA FOR ELIGABILITY
OH7200478OtherAETNA FOR ELIGABILITY