Provider Demographics
NPI:1609129402
Name:PREMIUM HEALTH, INC.
Entity Type:Organization
Organization Name:PREMIUM HEALTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:DOOLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-407-7300
Mailing Address - Street 1:620 FOSTER AVE
Mailing Address - Street 2:PREMIUM HEALTH, INC.
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-1399
Mailing Address - Country:US
Mailing Address - Phone:718-407-7300
Mailing Address - Fax:718-859-5717
Practice Address - Street 1:620 FOSTER AVE STE 200
Practice Address - Street 2:PREMIUM HEALTH, INC.
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-1399
Practice Address - Country:US
Practice Address - Phone:718-407-7300
Practice Address - Fax:718-859-5717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-18
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000000261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)