Provider Demographics
NPI:1811267214
Name:PREMIER PHYSICAL HEALTHCARE PLLC
Entity type:Organization
Organization Name:PREMIER PHYSICAL HEALTHCARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:MICHAELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-262-3315
Mailing Address - Street 1:115 W HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-1548
Mailing Address - Country:US
Mailing Address - Phone:218-262-3315
Mailing Address - Fax:218-263-9648
Practice Address - Street 1:115 W HOWARD ST
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-1548
Practice Address - Country:US
Practice Address - Phone:218-262-3315
Practice Address - Fax:218-263-9648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-03
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29671207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1811267214OtherBLUE CROSS BLUE SHIELD MN
MN1811267214Medicaid
MN1811267214Medicaid
MNC09123Medicare PIN