Healthcare Provider Details

I. General information

NPI: 1306105655
Provider Name (Legal Business Name): PREMIER MEDICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2012
Last Update Date: 08/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4050 HEALTHWAY DR SUITE 140
AURORA IL
60504-8183
US

IV. Provider business mailing address

4050 HEALTHWAY DR SUITE 140
AURORA IL
60504-8183
US

V. Phone/Fax

Practice location:
  • Phone: 630-318-3355
  • Fax: 630-701-9277
Mailing address:
  • Phone: 630-318-3355
  • Fax: 630-701-9277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number00303608379601
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209006778
License Number StateIL

VIII. Authorized Official

Name: DR. ALICE MARIE RUPP
Title or Position: OWNER
Credential: DO
Phone: 630-318-3355