Healthcare Provider Details

I. General information

NPI: 1356308761
Provider Name (Legal Business Name): PREMIER INTEGRATED MEDICAL ASSOC. LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 12/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7271 N MAIN ST SUITE 2
DAYTON OH
45415-2567
US

IV. Provider business mailing address

4700 SMITH RD SUITE A
CINCINNATI OH
45212-2787
US

V. Phone/Fax

Practice location:
  • Phone: 937-293-8322
  • Fax: 937-278-7112
Mailing address:
  • Phone: 513-619-6819
  • Fax: 513-645-2393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK COUCH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 937-898-3600