Healthcare Provider Details

I. General information

NPI: 1366046179
Provider Name (Legal Business Name): PREMIER MEDICAL ASSOCIATES OF FLORIDA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2020
Last Update Date: 11/16/2022
Certification Date: 11/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1580 SANTA BARBARA BLVD
THE VILLAGES FL
32159-6827
US

IV. Provider business mailing address

1580 SANTA BARBARA BLVD
THE VILLAGES FL
32159-6827
US

V. Phone/Fax

Practice location:
  • Phone: 352-259-2159
  • Fax:
Mailing address:
  • Phone: 352-259-2159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. SEEMA KHANNA
Title or Position: AUTHORISED OFFICIAL
Credential:
Phone: 352-259-2159