Healthcare Provider Details

I. General information

NPI: 1336107168
Provider Name (Legal Business Name): PREMIER INTEGRATED MEDICAL ASSOC LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 12/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4441 FAR HILLS AVE
KETTERING OH
45429-2405
US

IV. Provider business mailing address

4700 SMITH RD STE A
CINCINNATI OH
45212-2774
US

V. Phone/Fax

Practice location:
  • Phone: 937-298-7351
  • Fax: 937-298-9458
Mailing address:
  • Phone: 513-619-6819
  • Fax: 513-645-2393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

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