Provider Demographics
NPI:1235483306
Name:PREMIER PHYSICIANS OF NEW YORK PLLC
Entity Type:Organization
Organization Name:PREMIER PHYSICIANS OF NEW YORK PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:D
Authorized Official - Last Name:TERK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-309-8680
Mailing Address - Street 1:3599 UNIVERSITY BLVD S
Mailing Address - Street 2:SUITE 805
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4252
Mailing Address - Country:US
Mailing Address - Phone:904-309-8680
Mailing Address - Fax:904-345-5841
Practice Address - Street 1:1120 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-1242
Practice Address - Country:US
Practice Address - Phone:212-996-6660
Practice Address - Fax:212-996-2506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100078414Medicare PIN