Provider Demographics
NPI:1114648920
Name:PREMIER MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:PREMIER MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ROCHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:THAWLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-449-9314
Mailing Address - Street 1:620 STANTON CHRISTIANA RD STE 101
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2134
Mailing Address - Country:US
Mailing Address - Phone:302-449-7484
Mailing Address - Fax:
Practice Address - Street 1:620 STANTON CHRISTIANA RD STE 101
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2134
Practice Address - Country:US
Practice Address - Phone:302-449-7484
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREMIER MEDICAL ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-09-09
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE250691905Medicaid