Provider Demographics
NPI:1235461039
Name:PREMIERE CHILDRENS PHYSICANS, PA
Entity Type:Organization
Organization Name:PREMIERE CHILDRENS PHYSICANS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:LESTER
Authorized Official - Middle Name:BYRON
Authorized Official - Last Name:HORRELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-398-5930
Mailing Address - Street 1:719 NORTH BRIDGE STREET
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921
Mailing Address - Country:US
Mailing Address - Phone:410-398-5930
Mailing Address - Fax:410-398-0165
Practice Address - Street 1:701 N BRIDGE ST
Practice Address - Street 2:SUITE 104, NORTHSIDE PLAZA
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-5309
Practice Address - Country:US
Practice Address - Phone:410-398-5930
Practice Address - Fax:410-398-0165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0056952174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDF76738Medicare UPIN