Provider Demographics
NPI:1609077635
Name:PREMIER PHYSICIAN ALLIANCE
Entity Type:Organization
Organization Name:PREMIER PHYSICIAN ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:EVERETT
Authorized Official - Last Name:CORNFORTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-809-2005
Mailing Address - Street 1:PO BOX 2103
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93303-2103
Mailing Address - Country:US
Mailing Address - Phone:661-809-2005
Mailing Address - Fax:661-381-7545
Practice Address - Street 1:5001 CALIFORNIA AVE STE 202
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309-1692
Practice Address - Country:US
Practice Address - Phone:661-809-2005
Practice Address - Fax:661-381-7546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization