MEDICARE: PREMIER MEDICAL GROUP, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	36-101512	IL

General Provider Information

NPI Number	:	1639468788
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	1505 EASTLAND DR STE 500
Second Line	:
City	:	BLOOMINGTON
State	:	IL
Zip	:	61701-7905
Country	:	US
Telephone Number	:	309-662-2273
Fax Number	:	309-662-2014

Provider Business Practice Location Address
First Line	:	1505 EASTLAND DR STE 500
Second Line	:
City	:	BLOOMINGTON
State	:	IL
Zip	:	61701-7905
Country	:	US
Telephone Number	:	309-662-2273
Fax Number	:	309-662-2014

Authorized Official
Title or Position	:	EXECUTIVE ADMINISTRATOR
Name	:	JOHN HESSE
Credential	:
Telephone Number	:	309-662-6200

Provider Enumeration Date	:	03/29/2011
Last Update Date	:	03/29/2011

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