Provider Demographics
NPI:1518607738
Name:SJM PREMIER MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:SJM PREMIER MEDICAL GROUP, LLC
Other - Org Name:PREMIER MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE LEADERSHIP
Authorized Official - Prefix:
Authorized Official - First Name:NORA
Authorized Official - Middle Name:
Authorized Official - Last Name:UEHARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-234-1094
Mailing Address - Street 1:40-001 KMEHAMEHA HIGHWAY
Mailing Address - Street 2:SUITE 109
Mailing Address - City:KANEOHE
Mailing Address - State:HI
Mailing Address - Zip Code:96744
Mailing Address - Country:US
Mailing Address - Phone:520-372-8626
Mailing Address - Fax:520-372-8456
Practice Address - Street 1:3131 N COUNTRY CLUB RD STE 107-108
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-1649
Practice Address - Country:US
Practice Address - Phone:520-372-8626
Practice Address - Fax:520-372-8456
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SJM PREMIER MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-03-29
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI=========Medicaid