Healthcare Provider Details

I. General information

NPI: 1679741227
Provider Name (Legal Business Name): PREMIER INTEGRATED MEDICAL ASSOC. LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2008
Last Update Date: 02/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 LINCOLN PARK BLVD SUITE 110
KETTERING OH
45429-3492
US

IV. Provider business mailing address

500 LINCOLN PARK BLVD SUITE 110
KETTERING OH
45429-3492
US

V. Phone/Fax

Practice location:
  • Phone: 937-312-8155
  • Fax: 937-293-9231
Mailing address:
  • Phone: 937-312-8155
  • Fax: 937-293-9231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

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