Healthcare Provider Details

I. General information

NPI: 1487943593
Provider Name (Legal Business Name): PREMIER MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2011
Last Update Date: 03/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 EASTLAND DR SUITE 350
BLOOMINGTON IL
61701-3534
US

IV. Provider business mailing address

1505 EASTLAND DR SUITE 350
BLOOMINGTON IL
61701-3534
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-1222
  • Fax: 309-663-0580
Mailing address:
  • Phone: 309-663-1222
  • Fax: 309-663-0580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number36-084126
License Number StateIL

VIII. Authorized Official

Name: MR. JOHN HESSE
Title or Position: EXECUTIVE ADMINISTRATOR
Credential:
Phone: 309-662-6200