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General NPI Number Information
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NPI Number | 1497054720
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Entity Type | Organization
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Legal Business Name | PREMIER MEDICAL GROUP, LLC
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Dates
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Enumeration Date | 03/25/2011
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Last Update Date | 03/25/2011
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Provider Practice Location Address
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Address Line | 1512 W REYNOLDS ST STE A
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City | PONTIAC
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State | IL
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Zip | 61764-9788
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Country | US
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Telephone | 815-842-6551
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Fax | 815-844-4106
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Provider Business Mailing Address
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Address Line | 1512-A REYNOLDS
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City | PONTIAC
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State | IL
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Zip | 61764-1745
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Country | US
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Telephone | 815-842-6551
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Fax | 815-844-4106
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Authorized Official
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Title or Position | EXECUTIVE ADMINISTRATOR
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Name | MR. JOHN HESSE
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Credential |
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Telephone | 309-662-6200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 016-005106
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License Number State | IL
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