Provider Demographics
NPI:1134536451
Name:PREMIERMD IPA, LLC
Entity type:Organization
Organization Name:PREMIERMD IPA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:FATER
Authorized Official - Suffix:
Authorized Official - Credentials:COO
Authorized Official - Phone:954-561-5135
Mailing Address - Street 1:3465 GALT OCEAN DRIVE
Mailing Address - Street 2:203
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-7003
Mailing Address - Country:US
Mailing Address - Phone:954-561-5135
Mailing Address - Fax:954-561-5180
Practice Address - Street 1:3465 GALT OCEAN DRIVE
Practice Address - Street 2:203
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-7003
Practice Address - Country:US
Practice Address - Phone:954-561-5135
Practice Address - Fax:954-561-5180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-18
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty