Provider Demographics
NPI:1336313113
Name:PREMIER OB/GYN LLC
Entity Type:Organization
Organization Name:PREMIER OB/GYN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:MRS
Authorized Official - First Name:DECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOHAMMED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-429-2209
Mailing Address - Street 1:135 BLOOMFIELD AVE
Mailing Address - Street 2:SUITE L
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-5902
Mailing Address - Country:US
Mailing Address - Phone:973-429-2209
Mailing Address - Fax:973-429-2210
Practice Address - Street 1:135 BLOOMFIELD AVE
Practice Address - Street 2:SUITE L
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-5902
Practice Address - Country:US
Practice Address - Phone:973-429-2209
Practice Address - Fax:973-429-2210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07375800207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0002453Medicaid
NJ095068Medicare PIN