Provider Demographics
NPI:1427206739
Name:SUNCOAST PREMIER MEDICAL LLC
Entity Type:Organization
Organization Name:SUNCOAST PREMIER MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-207-6554
Mailing Address - Street 1:PO BOX 470459
Mailing Address - Street 2:
Mailing Address - City:CELEBRATION
Mailing Address - State:FL
Mailing Address - Zip Code:34747
Mailing Address - Country:US
Mailing Address - Phone:352-243-3555
Mailing Address - Fax:352-243-6614
Practice Address - Street 1:1239 US HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34714-8910
Practice Address - Country:US
Practice Address - Phone:352-243-3555
Practice Address - Fax:352-243-6614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-29
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME72969207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277533600Medicaid
FLG99597Medicare UPIN
47211XMedicare PIN