Provider Demographics
NPI:1891084653
Name:PREMIER MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:PREMIER MEDICAL GROUP, LLC
Other - Org Name:BARRY SLOTKY, M.D., SC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HESSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-662-6200
Mailing Address - Street 1:107 N REGENCY DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3505
Mailing Address - Country:US
Mailing Address - Phone:309-663-6338
Mailing Address - Fax:309-661-5644
Practice Address - Street 1:107 N REGENCY DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3505
Practice Address - Country:US
Practice Address - Phone:309-663-6338
Practice Address - Fax:309-661-5644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-01
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-047218207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty