Provider Demographics
NPI:1962682864
Name:PREMIER MEDICAL, PLLC
Entity Type:Organization
Organization Name:PREMIER MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFRY
Authorized Official - Middle Name:
Authorized Official - Last Name:TAMBOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-979-5880
Mailing Address - Street 1:PO BOX 141296
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-1296
Mailing Address - Country:US
Mailing Address - Phone:718-979-5880
Mailing Address - Fax:718-979-6476
Practice Address - Street 1:265 MASON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3412
Practice Address - Country:US
Practice Address - Phone:718-979-5880
Practice Address - Fax:718-979-6476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY158418207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01925915Medicaid
NY01925915Medicaid