Provider Demographics
NPI:1740242957
Name:PREMIER MEDICAL GROUP PC
Entity Type:Organization
Organization Name:PREMIER MEDICAL GROUP PC
Other - Org Name:PMEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:LIVERETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-245-7000
Mailing Address - Street 1:PO BOX 3799
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-3799
Mailing Address - Country:US
Mailing Address - Phone:931-245-7000
Mailing Address - Fax:
Practice Address - Street 1:490 DUNLOP LN
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5007
Practice Address - Country:US
Practice Address - Phone:931-245-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3164217OtherBCBS GROUP #
TNCA4837OtherRR MEDICARE
TNCA4837OtherRR MEDICARE
TN3706654Medicare PIN