Healthcare Provider Details

I. General information

NPI: 1447218631
Provider Name (Legal Business Name): PREMIER INTEGRATED MEDICAL ASSOC LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6520 ACRO COURT
CENTERVILLE OH
45459
US

IV. Provider business mailing address

25 MERCHANT ST STE 220 - ATTN CREDENTIALING
CINCINNATI OH
45246-3740
US

V. Phone/Fax

Practice location:
  • Phone: 937-291-6850
  • Fax: 937-291-6896
Mailing address:
  • Phone: 513-533-1199
  • Fax: 513-645-9827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK A COUCH
Title or Position: PRESIDENT
Credential: MD
Phone: 937-898-3600