Provider Demographics
NPI:1093411001
Name:PREMIER MD
Entity type:Organization
Organization Name:PREMIER MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:SKOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-514-8740
Mailing Address - Street 1:233 FOREST CT
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-5389
Mailing Address - Country:US
Mailing Address - Phone:618-510-9123
Mailing Address - Fax:618-822-4095
Practice Address - Street 1:233 FOREST CT
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-5389
Practice Address - Country:US
Practice Address - Phone:618-510-9123
Practice Address - Fax:618-822-4095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036130323Medicaid