Healthcare Provider Details

I. General information

NPI: 1396207437
Provider Name (Legal Business Name): PREMIER PHYSICIAN GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 04/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 ATRIUM WAY
COLUMBIA SC
29223-6301
US

IV. Provider business mailing address

2818 PARK ST
COLUMBIA SC
29201-1645
US

V. Phone/Fax

Practice location:
  • Phone: 803-381-2869
  • Fax: 864-484-8587
Mailing address:
  • Phone: 803-381-2869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DEZMOND SUMTER
Title or Position: PHYSICIAN
Credential: MD
Phone: 803-381-2869