NPIMap

Organization Active NPI

Premier Medical Group, LLC

Doing business as Katherine Widerborg, M.D.

  • Surgery Physician
  • Normal, IL
National Provider Identifier
1720377690
Registry record updated Mar 31, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Surgery PhysicianTaxonomy code 208600000X
License
36-068927 Issued in IL
Legal business name
PREMIER MEDICAL GROUP, LLC
Doing business as
Katherine Widerborg, M.D.
Practice address
1537 Fort Jesse Rd
Suite a
Normal, IL 61761-6192
Phone
(309) 808-0122
Fax
(309) 808-0522
NPI assigned
Mar 31, 2011
Last updated
Mar 31, 2011By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 31, 2011

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

Authorized official

Name
Mr. John Hesse
Title
Executive Administrator
Phone
(309) 662-6200

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Surgery PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 208600000X 36-068927 IL Primary

Addresses

Primary practice location

1537 Fort Jesse Rd
Suite a
Normal, IL 61761-6192

Mailing address

1537 Fort Jesse Rd
Suite a
Normal, IL 61761-6192
Phone (309) 808-0122

Other names 1

  • Katherine Widerborg, M.D. Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Premier Medical Group LLC12 organizations share this tax ID, including this one

Other organizations with this tax ID 11

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

NPI Registry JSON

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

{
    "created_epoch": "1301529600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1301529600000",
    "number": "1720377690",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1537 FORT JESSE RD",
            "address_2": "SUITE A",
            "city": "NORMAL",
            "state": "IL",
            "postal_code": "617616192",
            "telephone_number": "309-808-0122",
            "fax_number": "309-808-0522"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1537 FORT JESSE RD",
            "address_2": "SUITE A",
            "city": "NORMAL",
            "state": "IL",
            "postal_code": "617616192",
            "telephone_number": "309-808-0122",
            "fax_number": "309-808-0522"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PREMIER MEDICAL GROUP, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-03-31",
        "last_updated": "2011-03-31",
        "status": "A",
        "authorized_official_last_name": "HESSE",
        "authorized_official_first_name": "JOHN",
        "authorized_official_title_or_position": "EXECUTIVE ADMINISTRATOR",
        "authorized_official_telephone_number": "309-662-6200",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "208600000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Surgery",
            "state": "IL",
            "license": "36-068927",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Katherine Widerborg, M.D.",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Normal, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 31, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.