Provider Demographics
NPI:1710948443
Name:PREMIER MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:PREMIER MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:GAUDIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-388-1115
Mailing Address - Street 1:929 BOSTON POST RD
Mailing Address - Street 2:
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-2143
Mailing Address - Country:US
Mailing Address - Phone:860-388-1115
Mailing Address - Fax:
Practice Address - Street 1:929 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-2143
Practice Address - Country:US
Practice Address - Phone:860-388-1115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT26345207ND0900X, 207R00000X
CT042317207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT50PREMIERCT01OtherBLUE CROSS
CT50PREMIERCT01OtherBLUE CROSS