Healthcare Provider Details

I. General information

NPI: 1659684462
Provider Name (Legal Business Name): PREMIER HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2010
Last Update Date: 05/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2605 E CREEKS EDGE DR
BLOOMINGTON IN
47401-8368
US

IV. Provider business mailing address

550 S LANDMARK AVE
BLOOMINGTON IN
47403-3239
US

V. Phone/Fax

Practice location:
  • Phone: 812-355-2300
  • Fax: 812-355-2302
Mailing address:
  • Phone: 812-355-6900
  • Fax: 812-355-3251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. WESLEY W RATLIFF
Title or Position: PRESIDENT
Credential: M.D.
Phone: 812-355-6900