Provider Demographics
NPI:1407860752
Name:PREMIER CLINICS OF ROCK HILL
Entity Type:Organization
Organization Name:PREMIER CLINICS OF ROCK HILL
Other - Org Name:PREMIER CLINICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BAMIDELE
Authorized Official - Middle Name:A
Authorized Official - Last Name:EKUNSANMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-326-3000
Mailing Address - Street 1:PO BOX 36291
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-0504
Mailing Address - Country:US
Mailing Address - Phone:803-326-3000
Mailing Address - Fax:803-326-3003
Practice Address - Street 1:1609 CONSTITUTION BLVD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-3047
Practice Address - Country:US
Practice Address - Phone:803-326-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2019921261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3014Medicaid
SCG763109011Medicare UPIN
SCH788739011Medicare UPIN
SCGP3014Medicaid