Provider Demographics
NPI:1376908590
Name:PREMIER SURGEONS MANAGEMENT, LLC
Entity Type:Organization
Organization Name:PREMIER SURGEONS MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:MENEFEE
Authorized Official - Last Name:METTAUER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-471-5450
Mailing Address - Street 1:PO BOX 4248 DEPT #315
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4248
Mailing Address - Country:US
Mailing Address - Phone:936-283-0264
Mailing Address - Fax:
Practice Address - Street 1:17450 ST LUKES WAY STE 290
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77384-8045
Practice Address - Country:US
Practice Address - Phone:936-283-0264
Practice Address - Fax:936-828-2498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-15
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6486208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1560930-03Medicaid
TXH78289Medicare UPIN
TX8C0600Medicare PIN