Provider Demographics
NPI:1235149014
Name:PREMIER PEDIATRICS, LLC
Entity Type:Organization
Organization Name:PREMIER PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:BARBARA
Authorized Official - Last Name:PUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-929-2454
Mailing Address - Street 1:101 MED TECH PKWY
Mailing Address - Street 2:SUITE 405
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-4007
Mailing Address - Country:US
Mailing Address - Phone:423-929-2454
Mailing Address - Fax:
Practice Address - Street 1:101 MED TECH PKWY
Practice Address - Street 2:SUITE 405
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-4007
Practice Address - Country:US
Practice Address - Phone:423-929-2454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD16282208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNF00080Medicare UPIN