Provider Demographics
NPI:1679672505
Name:PREMIER MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:PREMIER MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:D
Authorized Official - Last Name:STURTEVANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-808-6081
Mailing Address - Street 1:PO BOX 1610
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26302-1610
Mailing Address - Country:US
Mailing Address - Phone:304-808-6081
Mailing Address - Fax:304-423-5032
Practice Address - Street 1:710 GENESIS BLVD
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9668
Practice Address - Country:US
Practice Address - Phone:304-808-6081
Practice Address - Fax:304-423-5032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207R00000X, 208000000X
WV51D0898849291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1540199OtherUMWA MEDICARE
WV001710500OtherBLUE CROSS BLUE SHIELD
WVCJ7607OtherRAILROAD MEDICARE
WV0010197000Medicaid
WV0010197000Medicaid
WV9272495Medicare PIN
WVCJ7607OtherRAILROAD MEDICARE
WV9272496Medicare PIN
WV=========OtherTAX ID NUMBER
WV9357231Medicare PIN
WV001710500OtherBLUE CROSS BLUE SHIELD