Provider Demographics
NPI:1265429872
Name:PREMIER FAMILY MEDICINE
Entity type:Organization
Organization Name:PREMIER FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WIECHMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-650-4347
Mailing Address - Street 1:2960 N CIRCLE DR STE 125
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-1164
Mailing Address - Country:US
Mailing Address - Phone:719-428-2065
Mailing Address - Fax:719-635-8333
Practice Address - Street 1:2960 N CIRCLE DR STE 125
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1164
Practice Address - Country:US
Practice Address - Phone:719-428-2065
Practice Address - Fax:719-635-8333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2021-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COE6308Medicare ID - Type Unspecified