Provider Demographics
NPI:1235186859
Name:PREMIERE ONCOLOGY, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PREMIERE ONCOLOGY, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PREISDENT AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:S
Authorized Official - Last Name:ROSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-633-8400
Mailing Address - Street 1:2020 SANTA MONICA BLVD STE 600
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2131
Mailing Address - Country:US
Mailing Address - Phone:310-633-8400
Mailing Address - Fax:310-633-8419
Practice Address - Street 1:2020 SANTA MONICA BLVD STE 600
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2131
Practice Address - Country:US
Practice Address - Phone:310-633-8400
Practice Address - Fax:310-633-8419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49741174400000X
CAG73680174400000X
CAA52720174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA49741OtherMEDICAL LICENSE - ROSEN
CAA52720OtherMEDICAL LICENSE - GARCIA
CAG73680OtherMEDICAL LICENSE - CHAP
CAG35932Medicare UPIN
CAF51386Medicare UPIN
CAW17316Medicare ID - Type UnspecifiedPROVIDER GROUP NUMBER
CA6225930001Medicare NSC
CAF69865Medicare UPIN