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General NPI Number Information
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NPI Number | 1093142895
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Entity Type | Organization
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Legal Business Name | PREMIER MEDICAL ALLIANCE LLC
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Dates
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Enumeration Date | 10/11/2013
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Last Update Date | 10/11/2013
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Provider Practice Location Address
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Address Line | 466 OLD HOOK ROAD SUITE 1
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City | EMERSON
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State | NJ
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Zip | 07630-1368
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Country | US
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Telephone | 201-967-8221
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Fax | 201-634-9647
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Provider Business Mailing Address
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Address Line | 466 OLD HOOK ROAD SUITE 1
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City | EMERSON
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State | NJ
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Zip | 07630-1368
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Country | US
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Telephone | 201-967-8221
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Fax | 201-634-9647
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ERIC AVEZZANO
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Credential | MD
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Telephone | 201-967-8221
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207K00000X
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Taxonomy Name | Allergy & Immunology Physician
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License Number | 25MA0806440
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 25MA05477400
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License Number State | NJ
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