Healthcare Provider Details

I. General information

NPI: 1831964022
Provider Name (Legal Business Name): PREMIER ALLERGIST OF FLORIDA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2023
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 SOUTHPARK BLVD STE 104
ST AUGUSTINE FL
32086-5179
US

IV. Provider business mailing address

4975 PRESTON PARK BLVD STE 800
PLANO TX
75093-5152
US

V. Phone/Fax

Practice location:
  • Phone: 904-826-3343
  • Fax: 904-826-3295
Mailing address:
  • Phone: 469-209-8355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL ALTMAN
Title or Position: VP RCM
Credential:
Phone: 469-209-8355