Provider Demographics
NPI:1194730713
Name:PREMIER INTERNAL MEDICINE GROUP SC
Entity type:Organization
Organization Name:PREMIER INTERNAL MEDICINE GROUP SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TAHIR
Authorized Official - Middle Name:
Authorized Official - Last Name:ROHAIL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-447-4267
Mailing Address - Street 1:2910 S HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-1785
Mailing Address - Country:US
Mailing Address - Phone:708-447-4267
Mailing Address - Fax:708-447-2104
Practice Address - Street 1:2910 HARLEM AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546-1785
Practice Address - Country:US
Practice Address - Phone:708-447-4267
Practice Address - Fax:708-447-2104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036087235207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036087235Medicaid
ILF92645Medicare UPIN
IL036087235Medicaid