Healthcare Provider Details

I. General information

NPI: 1396138319
Provider Name (Legal Business Name): PREMIER PHYSICIAN ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2015
Last Update Date: 03/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13651 HUNTERS OAK DR STE 101
ORLANDO FL
32837-7679
US

IV. Provider business mailing address

PO BOX 2648
ORLANDO FL
32802-2648
US

V. Phone/Fax

Practice location:
  • Phone: 321-946-6864
  • Fax:
Mailing address:
  • Phone: 321-946-6864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME90116
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME85807
License Number StateFL

VIII. Authorized Official

Name: DR. VIOLA JACOBS
Title or Position: OWNER
Credential: MD
Phone: 321-946-6864