Healthcare Provider Details

I. General information

NPI: 1053877506
Provider Name (Legal Business Name): PREMIER MED PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2019
Last Update Date: 10/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2906 17TH ST.
ST CLOUD FL
34769
US

IV. Provider business mailing address

7512 DR PHILLIPS BLVD STE 50-344
ORLANDO FL
32819-5420
US

V. Phone/Fax

Practice location:
  • Phone: 407-543-6306
  • Fax:
Mailing address:
  • Phone: 407-543-6306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAUVID BEHRAM AYADI
Title or Position: OWNER
Credential:
Phone: 407-352-2542