Provider Demographics
NPI:1184098212
Name:PREMIER OB-GYN LLC
Entity type:Organization
Organization Name:PREMIER OB-GYN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:L
Authorized Official - Last Name:HENRIKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:620-792-2151
Mailing Address - Street 1:514 CLEVELAND ST
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-3562
Mailing Address - Country:US
Mailing Address - Phone:620-792-2151
Mailing Address - Fax:620-793-9399
Practice Address - Street 1:514 CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-3562
Practice Address - Country:US
Practice Address - Phone:620-792-2151
Practice Address - Fax:620-793-9399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-01
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-30709207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty