Healthcare Provider Details

I. General information

NPI: 1740677087
Provider Name (Legal Business Name): PREMIER ORTHOPEDIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 04/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2557 S VAL VISTA DR STE. 103
GILBERT AZ
85295-6229
US

IV. Provider business mailing address

PO BOX 674074
DALLAS TX
75267-4074
US

V. Phone/Fax

Practice location:
  • Phone: 214-396-3936
  • Fax: 888-624-8659
Mailing address:
  • Phone: 214-396-3936
  • Fax: 888-624-8659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number41364
License Number StateAZ

VIII. Authorized Official

Name: MISS BRANDY K BARROW
Title or Position: TRANSACTION POSTER
Credential:
Phone: 214-396-3936