Provider Demographics
NPI:1689651184
Name:PREMIER INTERNAL MEDICINE LLC
Entity Type:Organization
Organization Name:PREMIER INTERNAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:SYED
Authorized Official - Middle Name:K
Authorized Official - Last Name:HUSSAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-304-1769
Mailing Address - Street 1:1347 ARBOR BLUFF CIR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-3701
Mailing Address - Country:US
Mailing Address - Phone:618-476-9399
Mailing Address - Fax:618-476-9547
Practice Address - Street 1:4500 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5360
Practice Address - Country:US
Practice Address - Phone:618-476-9399
Practice Address - Fax:618-476-9547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-27
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036092117207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036092117Medicaid
IL036092117Medicaid
K04224Medicare PIN
DB1989Medicare PIN
208376Medicare PIN