MEDICARE: PREMIER GASTROENTEROLOGY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician	207RG0100X	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	447788786-00	OTHER	OH	OHIO BWC
3	447788786002	OTHER	OH	MEDICAL MUTUAL OF OHIO

General Provider Information

NPI Number	:	1013999424
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER GASTROENTEROLOGY, INC.

Provider Business Mailing Address
First Line	:	1537 SOUTH BREIEL BOULEVARD
Second Line	:
City	:	MIDDLETOWN
State	:	OH
Zip	:	45044-6703
Country	:	US
Telephone Number	:	513-425-8300
Fax Number	:	513-425-8301

Provider Business Practice Location Address
First Line	:	1537 SOUTH BREIEL BOULEVARD
Second Line	:
City	:	MIDDLETOWN
State	:	OH
Zip	:	45044-6703
Country	:	US
Telephone Number	:	513-425-8300
Fax Number	:	513-425-8301

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DENNIS MIN
Credential	:	D.O.
Telephone Number	:	513-425-8300

Provider Enumeration Date	:	11/20/2005
Last Update Date	:	04/25/2014

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