Provider Demographics
NPI:1699704569
Name:PREMIER MEDICAL CENTER, INC
Entity type:Organization
Organization Name:PREMIER MEDICAL CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ENI
Authorized Official - Middle Name:CLEMENT
Authorized Official - Last Name:OKONOFUA
Authorized Official - Suffix:
Authorized Official - Credentials:MB,BS
Authorized Official - Phone:843-568-8330
Mailing Address - Street 1:PO BOX 31292
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29417-1292
Mailing Address - Country:US
Mailing Address - Phone:843-552-3099
Mailing Address - Fax:843-559-9037
Practice Address - Street 1:5390 DORCHESTER RD
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418-5652
Practice Address - Country:US
Practice Address - Phone:843-552-3099
Practice Address - Fax:843-552-3277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21076261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT53518Medicaid
SC=========OtherBCBS OF SC
SCG87820Medicare UPIN
SCT53518Medicaid