NPIMap

Organization Active NPI

Premier Pediatrics LLC

Doing business as Premier Pediatrics Forest

  • Primary Care Clinic/Center
  • Silver Springs, FL
National Provider Identifier
1104205632
Registry record updated May 29, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Clinic/CenterTaxonomy code 261QP2300X
Legal business name
PREMIER PEDIATRICS LLC
Doing business as
Premier Pediatrics Forest
Practice address
14141 E Highway 40 Unit B
Silver Springs, FL 34488-3933
Phone
(352) 512-0466
Fax
(352) 512-0374
NPI assigned
May 29, 2015
Last updated
May 29, 2015By the provider in NPPES
Organization subpart
Yes
Parent organization
PREMIER PEDIATRICS LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on May 29, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Farid Eunus
Title
Coo
Phone
(352) 671-6741

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Clinic/Center 261QP2300X NU Primary

Addresses

Primary practice location

14141 E Highway 40 Unit B
Silver Springs, FL 34488-3933

Mailing address

7960 SW 60TH Ave
Ocala, FL 34476-6457
Phone (352) 671-6741

Other names 1

  • Premier Pediatrics Forest Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20150611000064 FL Part A Provider - Rural Health Clinic 5294869236 Practice locations: Silver Springs, FL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1104205632. Details of each certification follow.

Rural health clinic certification: CCN 683818

Legal name
PREMIER PEDIATRICS LLC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 2, 2015
Last certification
Jul 20, 2022
Ownership / control type
1B
Organization structure
LLCProprietary
Incorporated
Jan 1, 2007 in FL
Enrollment address
14141 E Hwy 40, Unit B
Silver Springs, FL 34488-3933

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
10D2096675Premier Pediatrics14141 E Hwy 40 Ste B, Silver Springs, FL 34488Certificate of waiverMay 28, 2027

National Provider Directory

National Provider Directory
Tax ID family
Premier Pediatrics LLC7 organizations share this tax ID, including this one
Part of
Premier Pediatrics LLC

Other organizations with this tax ID 6

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 2

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Svetlana Y Rogozina Individual 5% Or Greater Direct Ownership Interest Apr 1, 2019 49%
Corporate OfficerVice President Apr 1, 2019 49%
Shahab Eunus Individual 5% Or Greater Direct Ownership Interest Nov 15, 2017 51%
W-2 Managing EmployeePresident Jan 1, 2007

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1432857600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1432857600000",
    "number": "1104205632",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7960 SW 60TH AVE",
            "city": "OCALA",
            "state": "FL",
            "postal_code": "344766457",
            "telephone_number": "352-671-6741",
            "fax_number": "352-671-6742"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "14141 E HIGHWAY 40 UNIT B",
            "city": "SILVER SPRINGS",
            "state": "FL",
            "postal_code": "344883933",
            "telephone_number": "352-512-0466",
            "fax_number": "352-512-0374"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PREMIER PEDIATRICS LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PREMIER PEDIATRICS LLC",
        "enumeration_date": "2015-05-29",
        "last_updated": "2015-05-29",
        "status": "A",
        "authorized_official_last_name": "EUNUS",
        "authorized_official_first_name": "FARID",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "352-671-6741"
    },
    "taxonomies": [
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Premier Pediatrics Forest",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Silver Springs, FL

Sources for this page

Verify at the official NPI Registry.