Healthcare Provider Details

I. General information

NPI: 1841589835
Provider Name (Legal Business Name): PREMIER MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2011
Last Update Date: 03/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 FRANKLIN AVE #4800
NORMAL IL
61761-3551
US

IV. Provider business mailing address

1302 FRANKLIN AVE #4800
NORMAL IL
61761-3551
US

V. Phone/Fax

Practice location:
  • Phone: 309-454-5900
  • Fax:
Mailing address:
  • Phone: 309-454-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number StateIL

VIII. Authorized Official

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