Provider Demographics
NPI:1427357227
Name:PREMIER MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:PREMIER MEDICAL GROUP, LLC
Other - Org Name:DRS. KULB, CHALIAN AND LEAK UROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HESSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-662-6200
Mailing Address - Street 1:1401 EASTLAND DR STE B
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3514
Mailing Address - Country:US
Mailing Address - Phone:309-663-9424
Mailing Address - Fax:309-663-6350
Practice Address - Street 1:1401 EASTLAND DR STE B
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3514
Practice Address - Country:US
Practice Address - Phone:309-663-9424
Practice Address - Fax:309-663-6350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-18
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty