Provider Demographics
NPI:1508160664
Name:PREMIER NEUROLOGY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:PREMIER NEUROLOGY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BIZ MGR
Authorized Official - Prefix:
Authorized Official - First Name:JOANN
Authorized Official - Middle Name:
Authorized Official - Last Name:PECORARO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-307-0074
Mailing Address - Street 1:415 N CRESCENT DR
Mailing Address - Street 2:STE 110
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210
Mailing Address - Country:US
Mailing Address - Phone:818-307-0074
Mailing Address - Fax:310-432-2889
Practice Address - Street 1:415 N CRESCENT DR
Practice Address - Street 2:STE 110
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210
Practice Address - Country:US
Practice Address - Phone:818-307-0074
Practice Address - Fax:310-432-2889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-04
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA509442084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG79898Medicare UPIN