=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073396073
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIER PHYSICIAN ASSOCIATES, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2023
-----------------------------------------------------
Last Update Date | 11/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 POND CT STE 301
-----------------------------------------------------
City | DEBARY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32713-2717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-259-4258
-----------------------------------------------------
Fax | 877-569-2113
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 POND CT STE 301
-----------------------------------------------------
City | DEBARY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32713-2717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-259-4258
-----------------------------------------------------
Fax | 877-569-2113
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | HAMIDREZA EBNESHAHIDI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 818-575-0095
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------