Healthcare Provider Details

I. General information

NPI: 1770623340
Provider Name (Legal Business Name): PREMIER HEART ASSOCIATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 10/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 W MARKET ST
LIMA OH
45801-4602
US

IV. Provider business mailing address

9000 N MAIN ST STE 101
DAYTON OH
45415-1180
US

V. Phone/Fax

Practice location:
  • Phone: 937-832-2425
  • Fax: 932-832-9804
Mailing address:
  • Phone: 937-832-2425
  • Fax: 937-832-9804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2212117
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer

VIII. Authorized Official

Name: GEORGE T BRODERICK JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 937-832-2425