Provider Demographics
NPI:1225228778
Name:PREMIER FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:PREMIER FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:YONG
Authorized Official - Middle Name:R
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-205-4544
Mailing Address - Street 1:86-35 QUEENS BLVD
Mailing Address - Street 2:1-E
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373
Mailing Address - Country:US
Mailing Address - Phone:718-205-4544
Mailing Address - Fax:718-205-5594
Practice Address - Street 1:86-35 QUEENS BLVD
Practice Address - Street 2:1-E
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373
Practice Address - Country:US
Practice Address - Phone:718-205-4544
Practice Address - Fax:718-205-5594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY209364207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06378OtherGHI-MEDICARE
NY06378OtherGHI-MEDICARE