Provider Demographics
NPI:1467534487
Name:PREMIER MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:PREMIER MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STACIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-894-2823
Mailing Address - Street 1:5005 S ASH AVE STE A-2
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-6837
Mailing Address - Country:US
Mailing Address - Phone:602-833-6585
Mailing Address - Fax:602-903-2333
Practice Address - Street 1:5030 S MILL AVE STE D12
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-6849
Practice Address - Country:US
Practice Address - Phone:480-894-2823
Practice Address - Fax:480-664-0828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ07538449R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ67803Medicare UPIN
AZD37863Medicare UPIN
AZG78761Medicare UPIN