Provider Demographics
NPI:1790749307
Name:PREMIER INTEGRATED MEDICAL ASSOCIATES, LTD
Entity Type:Organization
Organization Name:PREMIER INTEGRATED MEDICAL ASSOCIATES, LTD
Other - Org Name:PRIMED NORTHWEST DAYTON PEDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOLFENTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-836-9921
Mailing Address - Street 1:25 MERCHANT ST
Mailing Address - Street 2:STE. 220
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-3700
Mailing Address - Country:US
Mailing Address - Phone:513-533-6507
Mailing Address - Fax:513-645-9767
Practice Address - Street 1:120 W WENGER RD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-2762
Practice Address - Country:US
Practice Address - Phone:937-836-9921
Practice Address - Fax:937-836-1298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-12
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2080948Medicaid
OHH09285501Medicare ID - Type Unspecified