Provider Demographics
NPI:1619163904
Name:PREMIER HEALTH,P.A.
Entity Type:Organization
Organization Name:PREMIER HEALTH,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:WITTE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-739-1905
Mailing Address - Street 1:6861 UPPER AFTON RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4417
Mailing Address - Country:US
Mailing Address - Phone:651-739-1905
Mailing Address - Fax:651-738-5979
Practice Address - Street 1:6861 UPPER AFTON RD
Practice Address - Street 2:SUITE 102
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-4417
Practice Address - Country:US
Practice Address - Phone:651-739-1905
Practice Address - Fax:651-738-5979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1584261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN990727100Medicaid
MN990727100Medicaid