Provider Demographics
NPI:1285813147
Name:PREMIERE MEDICAL GROUP PA
Entity type:Organization
Organization Name:PREMIERE MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:LORENTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-676-7860
Mailing Address - Street 1:PO BOX 120043
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32912-0043
Mailing Address - Country:US
Mailing Address - Phone:321-676-7860
Mailing Address - Fax:321-952-7224
Practice Address - Street 1:2107 DAIRY RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-5209
Practice Address - Country:US
Practice Address - Phone:321-676-7860
Practice Address - Fax:321-956-8225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82880282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL262684500Medicaid
FL262684500Medicaid
FLK4153Medicare PIN