Provider Demographics
NPI:1720578313
Name:PREMIER GYNECOLOGY & WELLNESS, PLLC
Entity Type:Organization
Organization Name:PREMIER GYNECOLOGY & WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:BOX
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-650-7156
Mailing Address - Street 1:2310 RANDOLPH RD STE B
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2310 RANDOLPH RD STE B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1526
Practice Address - Country:US
Practice Address - Phone:704-650-7156
Practice Address - Fax:855-695-6439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-18
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-00351261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty