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General NPI Number Information
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NPI Number | 1093922072
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Entity Type | Organization
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Legal Business Name | PREMIER PEDIATRIC GROUP INC.
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Dates
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Enumeration Date | 05/17/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 5386 COX SMITH ROAD SUITE A
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City | MASON
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State | OH
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Zip | 45040
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Country | US
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Telephone | 513-770-3466
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Fax | 513-770-3467
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Provider Business Mailing Address
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Address Line | PO BOX 635228
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City | CINCINNATI
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State | OH
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Zip | 45263-0043
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Country | US
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Telephone | 513-770-3466
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Fax | 513-770-3467
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Authorized Official
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Title or Position | OWNER
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Name | DR. BRADLEY JACKSON
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Credential | M.D.
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Telephone | 513-770-3466
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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