MEDICARE: PREMIER ER SERVICES, 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	207P00000X	Emergency Medicine Physician	036.132627	IL

General Provider Information

NPI Number	:	1710315726
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER ER SERVICES, LLC

Provider Business Mailing Address
First Line	:	1867 N BISSELL ST
Second Line	:	UNIT #1A
City	:	CHICAGO
State	:	IL
Zip	:	60614-5012
Country	:	US
Telephone Number	:	317-213-9890
Fax Number	:

Provider Business Practice Location Address
First Line	:	1867 N BISSELL ST
Second Line	:	UNIT #1A
City	:	CHICAGO
State	:	IL
Zip	:	60614-5012
Country	:	US
Telephone Number	:	317-213-9890
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DAVID NGUYEN
Credential	:	D.O.
Telephone Number	:	317-213-9890

Provider Enumeration Date	:	10/30/2013
Last Update Date	:	11/13/2013

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