Healthcare Provider Details

I. General information

NPI: 1942501978
Provider Name (Legal Business Name): PREMIER MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2010
Last Update Date: 12/08/2023
Certification Date: 12/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 EASTLAND DR STE B
BLOOMINGTON IL
61701-3553
US

IV. Provider business mailing address

1401 EASTLAND DR STE B
BLOOMINGTON IL
61701-3553
US

V. Phone/Fax

Practice location:
  • Phone: 309-451-1123
  • Fax: 309-451-1212
Mailing address:
  • Phone: 309-451-1123
  • Fax: 309-451-1212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. PHIL ARTHUR MCGOWAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 309-451-1123