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General NPI Number Information
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NPI Number | 1942501978
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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 | 11/08/2010
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Last Update Date | 12/08/2023
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Provider Practice Location Address
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Address Line | 1401 EASTLAND DR STE B
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City | BLOOMINGTON
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State | IL
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Zip | 61701-3553
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Country | US
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Telephone | 309-451-1123
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Fax | 309-451-1212
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Provider Business Mailing Address
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Address Line | 1401 EASTLAND DR STE B
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City | BLOOMINGTON
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State | IL
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Zip | 61701-3553
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Country | US
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Telephone | 309-451-1123
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Fax | 309-451-1212
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. PHIL ARTHUR MCGOWAN
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Credential |
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Telephone | 309-451-1123
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number |
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License Number State |
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