Provider Demographics
NPI:1265522296
Name:PREMIUM HEALTHCARE PC
Entity type:Organization
Organization Name:PREMIUM HEALTHCARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:616-738-3998
Mailing Address - Street 1:3290 N WELLNESS DR
Mailing Address - Street 2:SUITE 220
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-7259
Mailing Address - Country:US
Mailing Address - Phone:616-738-3998
Mailing Address - Fax:
Practice Address - Street 1:3290 N WELLNESS DR
Practice Address - Street 2:SUITE 220
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-7259
Practice Address - Country:US
Practice Address - Phone:616-738-3998
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301036066207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP36300Medicare PIN
MIA73250Medicare UPIN