MEDICARE: PREMIER CLINICS OF ROCK HILL

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	261Q00000X	Clinic/Center	2019921	SC

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	:	1407860752
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER CLINICS OF ROCK HILL

Provider Business Mailing Address
First Line	:	PO BOX 36291
Second Line	:
City	:	ROCK HILL
State	:	SC
Zip	:	29732-0504
Country	:	US
Telephone Number	:	803-326-3000
Fax Number	:	803-326-3003

Provider Business Practice Location Address
First Line	:	1609 CONSTITUTION BLVD
Second Line	:
City	:	ROCK HILL
State	:	SC
Zip	:	29732-3047
Country	:	US
Telephone Number	:	803-326-3000
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/MEDICAL DIRECTOR
Name	:	DR. BAMIDELE A EKUNSANMI
Credential	:	M.D
Telephone Number	:	803-326-3000

Provider Enumeration Date	:	07/29/2006
Last Update Date	:	11/04/2008

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