MEDICARE: PREMIER OBGYN ASSOCIATES PLLC

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	207V00000X	Obstetrics & Gynecology Physician	ME89915	FL

General Provider Information

NPI Number	:	1164460143
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER OBGYN ASSOCIATES PLLC

Provider Business Mailing Address
First Line	:	1767 LAKEWOOD RANCH BLVD # 233
Second Line	:
City	:	BRADENTON
State	:	FL
Zip	:	34211-4906
Country	:	US
Telephone Number	:	941-745-5115
Fax Number	:	941-567-1000

Provider Business Practice Location Address
First Line	:	5323 4TH AVENUE CIR E
Second Line	:
City	:	BRADENTON
State	:	FL
Zip	:	34208-5623
Country	:	US
Telephone Number	:	941-745-5115
Fax Number	:	941-567-1000

Authorized Official
Title or Position	:	MANAGING DIRECTOR
Name	:	AARON MATTHEW SUDBURY
Credential	:	MD
Telephone Number	:	941-745-5115

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	03/09/2010

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