Provider Demographics
NPI:1194757617
Name:PREMIUM MEDICAL CARE LLC
Entity type:Organization
Organization Name:PREMIUM MEDICAL CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:AARON
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-494-9706
Mailing Address - Street 1:569 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-2630
Mailing Address - Country:US
Mailing Address - Phone:973-494-9706
Mailing Address - Fax:973-954-4360
Practice Address - Street 1:240 GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:PISCATAWAY
Practice Address - State:NJ
Practice Address - Zip Code:08854-2458
Practice Address - Country:US
Practice Address - Phone:973-494-9706
Practice Address - Fax:973-954-4360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC01309800104100000X
NJ25MA04542500207R00000X
NJ25MA06248800207R00000X
NJ25MA02906500207R00000X
NJ40QA00974100225100000X
NJ40QA00647800225100000X
NJTR00324500225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ082923Medicare ID - Type Unspecified