Provider Demographics
NPI:1902002116
Name:PREMIERCARE
Entity Type:Organization
Organization Name:PREMIERCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:KRUSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-927-8563
Mailing Address - Street 1:227 MIDLAND AVE STE 15B
Mailing Address - Street 2:
Mailing Address - City:BASALT
Mailing Address - State:CO
Mailing Address - Zip Code:81621-8119
Mailing Address - Country:US
Mailing Address - Phone:970-927-8563
Mailing Address - Fax:970-927-5245
Practice Address - Street 1:227 MIDLAND AVE STE 15B
Practice Address - Street 2:
Practice Address - City:BASALT
Practice Address - State:CO
Practice Address - Zip Code:81621-8119
Practice Address - Country:US
Practice Address - Phone:970-927-8563
Practice Address - Fax:970-927-5245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COG94047Medicare UPIN