Healthcare Provider Details

I. General information

NPI: 1184098212
Provider Name (Legal Business Name): PREMIER OB-GYN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2015
Last Update Date: 12/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 CLEVELAND ST
GREAT BEND KS
67530-3562
US

IV. Provider business mailing address

514 CLEVELAND ST
GREAT BEND KS
67530-3562
US

V. Phone/Fax

Practice location:
  • Phone: 620-792-2151
  • Fax: 620-793-9399
Mailing address:
  • Phone: 620-792-2151
  • Fax: 620-793-9399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number04-30709
License Number StateKS

VIII. Authorized Official

Name: JODI L HENRIKSON
Title or Position: PHYSICIAN
Credential: MD
Phone: 620-792-2151