Healthcare Provider Details

I. General information

NPI: 1942479084
Provider Name (Legal Business Name): PREMIER MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2008
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 ROUTE 98 W ST STE 103
NUTTER FORT WV
26301-4385
US

IV. Provider business mailing address

PO BOX 1610
CLARKSBURG WV
26302-1610
US

V. Phone/Fax

Practice location:
  • Phone: 304-623-1330
  • Fax: 304-623-1333
Mailing address:
  • Phone: 304-623-1330
  • Fax: 304-623-1333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateWV

VIII. Authorized Official

Name: MR. RONALD STACKPOLE
Title or Position: CFO
Credential:
Phone: 304-623-1330