Provider Demographics
NPI:1245645993
Name:PREMIER PHYSICIANS OF CENTRAL OHIO, LLC
Entity type:Organization
Organization Name:PREMIER PHYSICIANS OF CENTRAL OHIO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:HOPE
Authorized Official - Last Name:BONZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-813-0764
Mailing Address - Street 1:3136 KINGSDALE CTR STE 126
Mailing Address - Street 2:
Mailing Address - City:UPPER ARLINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43221-2000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4075 W DUBLIN GRANVILLE RD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-1436
Practice Address - Country:US
Practice Address - Phone:614-210-0541
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-20
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35087348207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2780647Medicaid
H129411Medicare PIN
H129410Medicare PIN
421864Medicare PIN