Provider Demographics
NPI:1306908926
Name:PREMIER SURGICAL GROUP, LLC
Entity type:Organization
Organization Name:PREMIER SURGICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAYLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:WEIRCOX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-779-3222
Mailing Address - Street 1:PO BOX 62
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-0062
Mailing Address - Country:US
Mailing Address - Phone:803-779-3222
Mailing Address - Fax:803-779-3223
Practice Address - Street 1:3019 FARROW RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-7001
Practice Address - Country:US
Practice Address - Phone:803-779-3222
Practice Address - Fax:803-779-3223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC26856208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCI16803Medicare UPIN
SCAA06338637Medicare PIN