Provider Demographics
NPI:1710229836
Name:PREMIER PHYSICAL MEDICINE LLC
Entity Type:Organization
Organization Name:PREMIER PHYSICAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TANNER
Authorized Official - Middle Name:P
Authorized Official - Last Name:HANCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-683-9500
Mailing Address - Street 1:6224 SHADYBROOK ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-1844
Mailing Address - Country:US
Mailing Address - Phone:316-683-9500
Mailing Address - Fax:316-683-9502
Practice Address - Street 1:3011 N UNION ST
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-7400
Practice Address - Country:US
Practice Address - Phone:316-683-9500
Practice Address - Fax:316-683-9502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty