Provider Demographics
NPI:1417915224
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 1:4700 SMITH RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-2787
Mailing Address - Country:US
Mailing Address - Phone:513-619-6819
Mailing Address - Fax:513-645-2393
Practice Address - Street 1:540 LINCOLN PARK BLVD
Practice Address - Street 2:SUITE 390
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-6401
Practice Address - Country:US
Practice Address - Phone:937-312-8150
Practice Address - Fax:937-312-8151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2691529Medicaid
OH2691529Medicaid
OH9348501Medicare PIN