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General NPI Number Information
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NPI Number | 1699978197
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Entity Type | Organization
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Legal Business Name | PREMIERMD
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Dates
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Enumeration Date | 06/11/2007
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Last Update Date | 09/16/2009
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Provider Practice Location Address
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Address Line | 757 ROUTE 202/206
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City | BRIDGEWATER
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State | NJ
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Zip | 08807-1763
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Country | US
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Telephone | 908-450-7002
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Fax | 732-832-2601
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Provider Business Mailing Address
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Address Line | 757 ROUTE 202/206
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City | BRIDGEWATER
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State | NJ
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Zip | 08807-1763
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Country | US
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Telephone | 908-450-7002
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Fax | 732-832-2601
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Authorized Official
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Title or Position | OWNER
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Name | DR. DAVID BOGUSLAVSKY
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Credential | M.D.
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Telephone | 908-450-7002
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | P-0227
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 25MA07932600
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License Number State | NJ
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