Provider Demographics
NPI:1801064704
Name:PREMIER PHYSICIAN GROUP, LLC
Entity type:Organization
Organization Name:PREMIER PHYSICIAN GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:G
Authorized Official - Last Name:POFFENROTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-896-6900
Mailing Address - Street 1:PO BOX 791372
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-1372
Mailing Address - Country:US
Mailing Address - Phone:301-896-6931
Mailing Address - Fax:301-581-0077
Practice Address - Street 1:6430 ROCKLEDGE DRIVE
Practice Address - Street 2:SUITE 470
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20817
Practice Address - Country:US
Practice Address - Phone:301-896-6931
Practice Address - Fax:301-581-0077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD415096100Medicaid
MD415096100Medicaid