Provider Demographics
NPI:1285690339
Name:PREMIER INTEGRATED MEDICAL ASSOC LTD
Entity Type:Organization
Organization Name:PREMIER INTEGRATED MEDICAL ASSOC LTD
Other - Org Name:PRIMED PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:COUCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-898-3600
Mailing Address - Street 1:1900 COMPOSITE DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45420-1475
Mailing Address - Country:US
Mailing Address - Phone:937-293-8419
Mailing Address - Fax:937-293-1545
Practice Address - Street 1:1900 COMPOSITE DR
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45420-1475
Practice Address - Country:US
Practice Address - Phone:937-293-8419
Practice Address - Fax:937-293-1545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2022-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTRICARE GROUP NUMBER
OH2112958Medicaid
OHCA2478OtherMEDICARE RR
=========015OtherTRICARE GROUP NUMBER