Healthcare Provider Details

I. General information

NPI: 1467534487
Provider Name (Legal Business Name): PREMIER MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 06/23/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5030 S MILL AVE STE D12
TEMPE AZ
85282-6849
US

IV. Provider business mailing address

5005 S ASH AVE STE A-2
TEMPE AZ
85282-6837
US

V. Phone/Fax

Practice location:
  • Phone: 480-894-2823
  • Fax: 480-664-0828
Mailing address:
  • Phone: 602-833-6585
  • Fax: 602-903-2333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number07538449R
License Number StateAZ

VIII. Authorized Official

Name: STACIA MENDEZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 480-894-2823