Provider Demographics
NPI:1760436190
Name:PREMIER HEALTHCARE, INC.
Entity Type:Organization
Organization Name:PREMIER HEALTHCARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:VLAD
Authorized Official - Middle Name:
Authorized Official - Last Name:KUZNETSOV
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, MBA, PA
Authorized Official - Phone:212-273-6116
Mailing Address - Street 1:460 W 34TH ST
Mailing Address - Street 2:FL 11
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-2382
Mailing Address - Country:US
Mailing Address - Phone:212-273-6330
Mailing Address - Fax:212-273-6427
Practice Address - Street 1:460 WEST 34TH STREET
Practice Address - Street 2:9TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-2382
Practice Address - Country:US
Practice Address - Phone:212-273-6519
Practice Address - Fax:212-273-6427
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREMIER HEALTHCARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-20
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7002154R261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01751000Medicaid
NY01751000Medicaid
NYWX0931Medicare PIN
NYWX0931Medicare ID - Type UnspecifiedMANHATTAN CLINIC
NY03807Medicare ID - Type UnspecifiedQUEENS BAYSIDE