Provider Demographics
NPI:1639740624
Name:PREMIER PEDIATRICS LLC
Entity Type:Organization
Organization Name:PREMIER PEDIATRICS LLC
Other - Org Name:PREMIER PEDIATRICS FOREST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAHAB
Authorized Official - Middle Name:
Authorized Official - Last Name:EUNUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-671-6741
Mailing Address - Street 1:7960 SW 60TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34476-6457
Mailing Address - Country:US
Mailing Address - Phone:352-671-6741
Mailing Address - Fax:352-671-6742
Practice Address - Street 1:14141 E HIGHWAY 40
Practice Address - Street 2:
Practice Address - City:SILVER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34488-3910
Practice Address - Country:US
Practice Address - Phone:352-512-0466
Practice Address - Fax:352-512-0374
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREMIER PEDIATRICS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-07-09
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111314300Medicaid