Provider Demographics
NPI:1497054720
Name:PREMIER MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:PREMIER MEDICAL GROUP, LLC
Other - Org Name:SCOTT O'CONNOR, DPM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE ADMINISTRATOR
Authorized Official - Prefix:MR
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 1:1512-A REYNOLDS
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-1745
Mailing Address - Country:US
Mailing Address - Phone:815-842-6551
Mailing Address - Fax:815-844-4106
Practice Address - Street 1:1512 W REYNOLDS ST STE A
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-9788
Practice Address - Country:US
Practice Address - Phone:815-842-6551
Practice Address - Fax:815-844-4106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-25
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-005106213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty