Provider Demographics
NPI:1790880623
Name:PREMIER PRIMARY CARE, PLC
Entity Type:Organization
Organization Name:PREMIER PRIMARY CARE, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:MR
Authorized Official - First Name:DIPES
Authorized Official - Middle Name:K
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-410-8745
Mailing Address - Street 1:113 GAINSBOROUGH SQ STE 201
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-1714
Mailing Address - Country:US
Mailing Address - Phone:757-410-8745
Mailing Address - Fax:757-410-8746
Practice Address - Street 1:113 GAINSBOROUGH SQ STE 201
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-1714
Practice Address - Country:US
Practice Address - Phone:757-410-8745
Practice Address - Fax:757-410-8746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAH82305207Q00000X
VAG66860207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1109507OtherFIRST HEALTH
173326 / 173327OtherANTHEM
2182480OtherFIRST HEALTH
91697OtherOPTIMA
VAP00099937OtherRAILROAD MEDICARE
0007777515OtherAETNA
114879 / 114964OtherANTHEM
3342321OtherCIGNA
70343OtherOPTIMA
7596518OtherCIGNA
7687230OtherAETNA
7687230OtherAETNA
7596518OtherCIGNA
VAH82305Medicare UPIN
1109507OtherFIRST HEALTH
2182480OtherFIRST HEALTH