Provider Demographics
NPI:1720377690
Name:PREMIER MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:PREMIER MEDICAL GROUP, LLC
Other - Org Name:KATHERINE WIDERBORG, M.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HESSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-662-6200
Mailing Address - Street 1:1537 FORT JESSE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-6192
Mailing Address - Country:US
Mailing Address - Phone:309-808-0122
Mailing Address - Fax:309-808-0522
Practice Address - Street 1:1537 FORT JESSE RD
Practice Address - Street 2:SUITE A
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6192
Practice Address - Country:US
Practice Address - Phone:309-808-0122
Practice Address - Fax:309-808-0522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-31
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-068927208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty