Provider Demographics
NPI:1639136013
Name:PREMIER INTEGRATED MEDICAL ASSOC LTD
Entity Type:Organization
Organization Name:PREMIER INTEGRATED MEDICAL ASSOC LTD
Other - Org Name:PRIMED PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:COUCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-898-3600
Mailing Address - Street 1:4700 SMITH RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-2787
Mailing Address - Country:US
Mailing Address - Phone:513-619-6819
Mailing Address - Fax:513-645-2393
Practice Address - Street 1:4000 MIAMISBURG CENTERVILLE RD
Practice Address - Street 2:SUITE 104
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342
Practice Address - Country:US
Practice Address - Phone:937-859-1117
Practice Address - Fax:937-859-9038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2478OtherMEDICARE RR GROUP NUMBER
OH2178558Medicaid
314422758001OtherTRICARE GROUP NUMBER
CA2478OtherMEDICARE RR GROUP NUMBER