MEDICARE: PREMIER INTEGRATED MEDICAL ASSOC LTD

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	207Q00000X	Family Medicine Physician

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

General Provider Information

NPI Number	:	1336106798
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER INTEGRATED MEDICAL ASSOC LTD

Provider Business Mailing Address
First Line	:	4700 SMITH RD
Second Line	:	SUITE A
City	:	CINCINNATI
State	:	OH
Zip	:	45212-2787
Country	:	US
Telephone Number	:	513-619-6819
Fax Number	:	513-645-2393

Provider Business Practice Location Address
First Line	:	896 S MAIN STREET
Second Line	:
City	:	CENTERVILLE
State	:	OH
Zip	:	45458-3439
Country	:	US
Telephone Number	:	937-436-3117
Fax Number	:	937-436-0730

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARK A COUCH
Credential	:	MD
Telephone Number	:	937-898-3600

Provider Enumeration Date	:	04/28/2006
Last Update Date	:	12/30/2009

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