=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396207437
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIER PHYSICIAN GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2019
-----------------------------------------------------
Last Update Date | 04/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 ATRIUM WAY
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29223-6301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-381-2869
-----------------------------------------------------
Fax | 864-484-8587
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2818 PARK ST
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29201-1645
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-381-2869
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. DEZMOND SUMTER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 803-381-2869
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 202C00000X
-----------------------------------------------------
Taxonomy Name | Independent Medical Examiner Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------