Provider Demographics
NPI:1942578554
Name:PREMIERE HEALTH AND WELLNESS MEDICAL CENTER
Entity Type:Organization
Organization Name:PREMIERE HEALTH AND WELLNESS MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:VENUS
Authorized Official - Middle Name:IDETTE
Authorized Official - Last Name:PITTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-416-4700
Mailing Address - Street 1:2609 N DUKE ST
Mailing Address - Street 2:SUITE 403
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-3048
Mailing Address - Country:US
Mailing Address - Phone:919-416-4700
Mailing Address - Fax:919-416-0821
Practice Address - Street 1:2609 N DUKE ST
Practice Address - Street 2:SUITE 403
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-3048
Practice Address - Country:US
Practice Address - Phone:919-416-4700
Practice Address - Fax:919-416-0821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-09
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC145584207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2026035AOtherMEDICARE ID
NC89136E4Medicaid
I0818Medicare UPIN
NCI08128Medicare UPIN