Provider Demographics
NPI:1942501978
Name:PREMIER MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:PREMIER MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PHIL
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:MCGOWAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-451-1123
Mailing Address - Street 1:1401 EASTLAND DR STE B
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3553
Mailing Address - Country:US
Mailing Address - Phone:309-451-1123
Mailing Address - Fax:309-451-1212
Practice Address - Street 1:1401 EASTLAND DR STE B
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3553
Practice Address - Country:US
Practice Address - Phone:309-451-1123
Practice Address - Fax:309-451-1212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-08
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty