Provider Demographics
NPI:1255511978
Name:PREMIER MED REHAB INC
Entity type:Organization
Organization Name:PREMIER MED REHAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAMUNA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIVAKANTHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:412-918-2408
Mailing Address - Street 1:4810 LIBERTY AVENUE
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15224-2108
Mailing Address - Country:US
Mailing Address - Phone:412-918-2408
Mailing Address - Fax:412-918-2411
Practice Address - Street 1:4810 LIBERTY AVENUE
Practice Address - Street 2:SUITE 1000
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15224-2108
Practice Address - Country:US
Practice Address - Phone:412-918-2408
Practice Address - Fax:412-918-2411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA062181L208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1702643Medicaid
PA780359Medicare UPIN