Provider Demographics
NPI:1922287317
Name:PREMIER COMPREHENSIVE MANAGEMENT SERVICES, LLC
Entity Type:Organization
Organization Name:PREMIER COMPREHENSIVE MANAGEMENT SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:WIEDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-895-5056
Mailing Address - Street 1:PO BOX 74169
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44194-4169
Mailing Address - Country:US
Mailing Address - Phone:440-895-5056
Mailing Address - Fax:440-333-2935
Practice Address - Street 1:20525 CENTER RIDGE RD
Practice Address - Street 2:SUITE 220
Practice Address - City:ROCKY RIVER
Practice Address - State:OH
Practice Address - Zip Code:44116-3437
Practice Address - Country:US
Practice Address - Phone:440-895-5056
Practice Address - Fax:440-333-2935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-01
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2916152Medicaid
OH2916152Medicaid