Healthcare Provider Details

I. General information

NPI: 1801853262
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: 04/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243 W CENTRAL AVE
SPRINGBORO OH
45066-1103
US

IV. Provider business mailing address

25 MERCHANT ST STE 220
CINCINNATI OH
45246-3740
US

V. Phone/Fax

Practice location:
  • Phone: 937-748-4814
  • Fax: 937-748-4896
Mailing address:
  • Phone: 513-533-1199
  • Fax: 513-645-9827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier2178423
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer

VIII. Authorized Official

Name: DR. MARK A COUCH
Title or Position: PRESIDENT
Credential: MD
Phone: 937-898-5600