| Premier Medical Group, Llc | |
|
1401 Eastland Dr Ste B Bloomington IL 61701-3553 | |
| (309) 451-1123 | |
| (309) 451-1212 |
| Full Name | Premier Medical Group, Llc |
|---|---|
| Speciality | Surgery |
| Location | 1401 Eastland Dr Ste B, Bloomington, Illinois |
| Authorized Official Name and Position | Phil Arthur Mcgowan (ADMINISTRATOR) |
| Authorized Official Contact | 3094511123 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Premier Medical Group, Llc 1401 Eastland Dr Ste B Bloomington IL 61701-3553 Ph: (309) 451-1123 | Premier Medical Group, Llc 1401 Eastland Dr Ste B Bloomington IL 61701-3553 Ph: (309) 451-1123 |
| NPI Number | 1942501978 |
|---|---|
| Provider Enumeration Date | 11/08/2010 |
| Last Update Date | 12/08/2023 |
| Medicare PECOS PAC ID | 5991989477 |
|---|---|
| Medicare Enrollment ID | O20110407000129 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1942501978 | NPI | - | NPPES |
| Provider Name | Roy Garland Haynes |
|---|---|
| Provider Type | Practitioner - Certified Registered Nurse Anesthetist (crna) |
| Provider Identifiers | NPI Number: 1174636989 PECOS PAC ID: 7416847629 Enrollment ID: I20040319000081 |
| Provider Name | Benjamin J Leak |
|---|---|
| Provider Type | Practitioner - Urology |
| Provider Identifiers | NPI Number: 1043248867 PECOS PAC ID: 5698763811 Enrollment ID: I20040505000492 |
| Provider Name | Jennifer L Frazier |
|---|---|
| Provider Type | Practitioner - Certified Registered Nurse Anesthetist (crna) |
| Provider Identifiers | NPI Number: 1780612812 PECOS PAC ID: 3678555711 Enrollment ID: I20040603000135 |
| Provider Name | Renuka A Bhaskar |
|---|---|
| Provider Type | Practitioner - Pathology |
| Provider Identifiers | NPI Number: 1235163056 PECOS PAC ID: 9032185988 Enrollment ID: I20040902000728 |
| Provider Name | Catherine S Gleason-dintaman |
|---|---|
| Provider Type | Practitioner - Certified Registered Nurse Anesthetist (crna) |
| Provider Identifiers | NPI Number: 1730165762 PECOS PAC ID: 2264495951 Enrollment ID: I20041104000113 |
| Provider Name | Stephen S Matter |
|---|---|
| Provider Type | Practitioner - Gastroenterology |
| Provider Identifiers | NPI Number: 1134228224 PECOS PAC ID: 7416989330 Enrollment ID: I20050901000008 |
| Provider Name | Vicken S Chalian |
|---|---|
| Provider Type | Practitioner - Urology |
| Provider Identifiers | NPI Number: 1871529594 PECOS PAC ID: 4688669799 Enrollment ID: I20100809001028 |
| Provider Name | Summer A Hinthorne |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1831416189 PECOS PAC ID: 0244484244 Enrollment ID: I20130128000484 |
| Provider Name | Justin J Couch |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1922451681 PECOS PAC ID: 0446546196 Enrollment ID: I20160907001680 |
| Provider Name | Anastasia V Kovalaske |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1790118586 PECOS PAC ID: 1759668742 Enrollment ID: I20170428001644 |
| Provider Name | Salvatore Catarinicchia |
|---|---|
| Provider Type | Practitioner - Urology |
| Provider Identifiers | NPI Number: 1912240466 PECOS PAC ID: 1355654740 Enrollment ID: I20190801002166 |
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