MEDICARE: PREMIER HEALTHCARE, INC.

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	261QD1600X	Developmental Disabilities Clinic/Center		NY

General Provider Information

NPI Number	:	1831330182
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER HEALTHCARE, INC.

Provider Business Mailing Address
First Line	:	460 W 34TH ST FL 11
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10001-2382
Country	:	US
Telephone Number	:	212-273-6100
Fax Number	:

Provider Business Practice Location Address
First Line	:	460 WEST 34TH STREET
Second Line	:	9TH FLOOR
City	:	NEW YORK
State	:	NY
Zip	:	10001-2382
Country	:	US
Telephone Number	:	212-273-6519
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. VLAD KUZNETSOV
Credential	:	PHD, MBA, PA
Telephone Number	:	212-273-6116

Provider Enumeration Date	:	03/17/2009
Last Update Date	:	04/27/2017

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