Provider Demographics
NPI:1942479084
Name:PREMIER MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:PREMIER MEDICAL GROUP, INC.
Other - Org Name:PREMIER MEDICAL GROUP LAB
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:STACKPOLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-623-1330
Mailing Address - Street 1:PO BOX 1610
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26302-1610
Mailing Address - Country:US
Mailing Address - Phone:304-623-1330
Mailing Address - Fax:304-623-1333
Practice Address - Street 1:200 ROUTE 98 W ST
Practice Address - Street 2:STE 103
Practice Address - City:NUTTER FORT
Practice Address - State:WV
Practice Address - Zip Code:26301-4385
Practice Address - Country:US
Practice Address - Phone:304-623-1330
Practice Address - Fax:304-623-1333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0038573000Medicaid
WV0038573000Medicaid