Healthcare Provider Details

I. General information

NPI: 1417915224
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: 08/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 LINCOLN PARK BLVD SUITE 390
KETTERING OH
45429-6401
US

IV. Provider business mailing address

4700 SMITH RD SUITE A
CINCINNATI OH
45212-2787
US

V. Phone/Fax

Practice location:
  • Phone: 937-312-8150
  • Fax: 937-312-8151
Mailing address:
  • Phone: 513-619-6819
  • Fax: 513-645-2393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal 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