Provider Demographics
NPI:1801853262
Name:PREMIER INTEGRATED MEDICAL ASSOC LTD
Entity Type:Organization
Organization Name:PREMIER INTEGRATED MEDICAL ASSOC LTD
Other - Org Name:PRIMED PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:COUCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-898-5600
Mailing Address - Street 1:25 MERCHANT ST STE 220
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-3740
Mailing Address - Country:US
Mailing Address - Phone:513-533-1199
Mailing Address - Fax:513-645-9827
Practice Address - Street 1:243 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-1103
Practice Address - Country:US
Practice Address - Phone:937-748-4814
Practice Address - Fax:937-748-4896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2178423Medicaid
OH2178423Medicaid
CA2478Medicare PIN
=========006OtherTRICARE GROUP NUMBER
OH2178423Medicaid