Provider Demographics
NPI:1306413927
Name:PREMIUM MEDICAL ASSOCIATES HEALTHCARE LLC
Entity Type:Organization
Organization Name:PREMIUM MEDICAL ASSOCIATES HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:LYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:PIERRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-860-1511
Mailing Address - Street 1:4651 BABCOCK ST NE STE 18
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-2808
Mailing Address - Country:US
Mailing Address - Phone:407-498-6934
Mailing Address - Fax:407-386-7878
Practice Address - Street 1:600 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32306
Practice Address - Country:US
Practice Address - Phone:407-498-6934
Practice Address - Fax:407-386-7878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty