Provider Demographics
NPI:1013999424
Name:PREMIER GASTROENTEROLOGY, INC.
Entity Type:Organization
Organization Name:PREMIER GASTROENTEROLOGY, INC.
Other - Org Name:PREMIER GASTROENTEROLOGY, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:513-425-8300
Mailing Address - Street 1:1537 SOUTH BREIEL BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45044-6703
Mailing Address - Country:US
Mailing Address - Phone:513-425-8300
Mailing Address - Fax:513-425-8301
Practice Address - Street 1:1537 SOUTH BREIEL BOULEVARD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-6703
Practice Address - Country:US
Practice Address - Phone:513-425-8300
Practice Address - Fax:513-425-8301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-20
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207RG0100X207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2460877Medicaid
OH447788786-00OtherOHIO BWC
OH447788786002OtherMEDICAL MUTUAL OF OHIO
OH=========OtherTAX ID#
OH9355321Medicare ID - Type UnspecifiedOHIO MEDICARE GROUP #