=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164460143
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIER OBGYN ASSOCIATES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2006
-----------------------------------------------------
Last Update Date | 03/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5323 4TH AVENUE CIR E
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34208-5623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-745-5115
-----------------------------------------------------
Fax | 941-567-1000
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1767 LAKEWOOD RANCH BLVD # 233
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34211-4906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-745-5115
-----------------------------------------------------
Fax | 941-567-1000
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING DIRECTOR
-----------------------------------------------------
Name | AARON MATTHEW SUDBURY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 941-745-5115
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | ME89915
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------