Healthcare Provider Details

I. General information

NPI: 1679672505
Provider Name (Legal Business Name): PREMIER MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 07/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 GENESIS BLVD
BRIDGEPORT WV
26330-9668
US

IV. Provider business mailing address

PO BOX 1610
CLARKSBURG WV
26302-1610
US

V. Phone/Fax

Practice location:
  • Phone: 304-808-6081
  • Fax: 304-423-5032
Mailing address:
  • Phone: 304-808-6081
  • Fax: 304-423-5032

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 Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number51D0898849
License Number StateWV

VIII. Authorized Official

Name: MRS. CHRISTINE D STURTEVANT
Title or Position: CEO
Credential:
Phone: 304-808-6081