Provider Demographics
NPI:1295965986
Name:PREMIUM CARE MED GROUP INC
Entity type:Organization
Organization Name:PREMIUM CARE MED GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TED
Authorized Official - Middle Name:M
Authorized Official - Last Name:PENNEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-422-8719
Mailing Address - Street 1:3828 SALEM RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-4528
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3828 SALEM RD
Practice Address - Street 2:SUITE 200
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016-4528
Practice Address - Country:US
Practice Address - Phone:404-422-8719
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-16
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029068207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty