Provider Demographics
NPI:1760738207
Name:PREMIER GENERAL AND COLORECTAL SURGERY, PA
Entity Type:Organization
Organization Name:PREMIER GENERAL AND COLORECTAL SURGERY, PA
Other - Org Name:PREMIER GENERAL AND COLORECTAL SURGERY PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-303-2922
Mailing Address - Street 1:129 VISION PARK BLVD STE 212
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77384-3024
Mailing Address - Country:US
Mailing Address - Phone:832-303-2922
Mailing Address - Fax:866-923-1223
Practice Address - Street 1:129 VISION PARK BLVD STE 212
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77384-3024
Practice Address - Country:US
Practice Address - Phone:832-303-2922
Practice Address - Fax:866-923-1223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN3791174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
K0169364OtherDPS
N3791OtherLICENSE
FK1029291OtherDEA