MEDICARE: SJM PREMIER MEDICAL GROUP, LLC

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	261QP2300X	Primary Care Clinic/Center

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	:	1518607738
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SJM PREMIER MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	40-001 KMEHAMEHA HIGHWAY
Second Line	:	SUITE 109
City	:	KANEOHE
State	:	HI
Zip	:	96744
Country	:	US
Telephone Number	:	520-372-8626
Fax Number	:	520-372-8456

Provider Business Practice Location Address
First Line	:	3131 N COUNTRY CLUB RD STE 107-108
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85716-1649
Country	:	US
Telephone Number	:	520-372-8626
Fax Number	:	520-372-8456

Authorized Official
Title or Position	:	EXECUTIVE LEADERSHIP
Name	:	NORA UEHARA
Credential	:
Telephone Number	:	808-234-1094

Provider Enumeration Date	:	03/29/2022
Last Update Date	:	05/02/2022

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