Provider Demographics
NPI:1194296533
Name:PREMIUM PRACTITIONERS PLUS INC.
Entity type:Organization
Organization Name:PREMIUM PRACTITIONERS PLUS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP-BC
Authorized Official - Prefix:DR
Authorized Official - First Name:TALIA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON- JONES
Authorized Official - Suffix:
Authorized Official - Credentials:FPA APRN, DNP
Authorized Official - Phone:708-991-2945
Mailing Address - Street 1:5331 STANFORD LN
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-1671
Mailing Address - Country:US
Mailing Address - Phone:708-600-0965
Mailing Address - Fax:
Practice Address - Street 1:19801 GOVERNORS HWY STE 140
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-4363
Practice Address - Country:US
Practice Address - Phone:708-635-6484
Practice Address - Fax:312-585-5620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-11
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400625230Medicaid