Healthcare Provider Details

I. General information

NPI: 1164460143
Provider Name (Legal Business Name): PREMIER OBGYN ASSOCIATES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 03/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5323 4TH AVENUE CIR E
BRADENTON FL
34208-5623
US

IV. Provider business mailing address

1767 LAKEWOOD RANCH BLVD # 233
BRADENTON FL
34211-4906
US

V. Phone/Fax

Practice location:
  • Phone: 941-745-5115
  • Fax: 941-567-1000
Mailing address:
  • Phone: 941-745-5115
  • Fax: 941-567-1000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME89915
License Number StateFL

VIII. Authorized Official

Name: AARON MATTHEW SUDBURY
Title or Position: MANAGING DIRECTOR
Credential: MD
Phone: 941-745-5115