NPIMap

Organization Active NPI

Premier Community Healthcare Group Inc

  • Federally Qualified Health Center (FQHC)
  • Dade City, FL
National Provider Identifier
1841263399
Registry record updated Oct 9, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
PREMIER COMMUNITY HEALTHCARE GROUP INC
Practice address
14027 5TH St
Dade City, FL 33525-4302
Phone
(352) 518-2000
Fax
(352) 567-0218
NPI assigned
Feb 7, 2006
Last updated
Oct 9, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 9, 2019

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

Authorized official

Name
Jennifer Maffett
Title
Health Data Analyst
Phone
(352) 518-2000

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice Physician 208D00000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

14027 5TH St
Dade City, FL 33525-4302

Mailing address

PO Box 232
Dade City, FL 33526-0232
Phone (352) 518-2000

Other identifiers 1

IdentifierTypeStateIssuer
029550700MedicaidFL

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031215000701 FL Part B Supplier - Clinic/Group Practice 3476450818 Receives reassigned benefits from 77 practitioners
Practice locations: Dade City, FL
O20040930000588 FL Part A Provider - Federally Qualified Health Center (FQHC) 3476450818 Practice locations: Dade City, FL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1841263399. Details of each certification follow.

Federally qualified health center certification: CCN 101842

Legal name
PREMIER COMMUNITY HEALTH CARE GROUP INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 1, 1991
Last certification
Oct 1, 1991
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Jul 29, 1979 in FL
Enrollment address
14027 5TH St
Dade City, FL 33525-4302

Other NPIs with the same Medicare PAC ID 9

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
10D2245594Premier Community Healthcare Group Inc14027 5TH Street, Dade City, FL 33525Certificate of waiverDec 13, 2027

National Provider Directory

National Provider Directory

Locations

14027 5th St
Dade City, FL 33525
Phone (813) 782-6064

37946 Church Ave
Dade City, FL 33525

Ownership & related parties

All disclosed owners & managing parties 6

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

NameRoleSinceShare
Joseph Resnick Individual Corporate OfficerCeo Aug 22, 2014 100%
W-2 Managing EmployeeCeo Aug 22, 2014 100%
Nelson Cruz Individual Corporate OfficerBoard Member Sep 30, 2013
Dawn Enright Individual Corporate OfficerBoard Member Dec 1, 2013
William Gregg Individual Corporate OfficerBoard Member Dec 1, 2013
Tom Stearns Individual Corporate OfficerBoard Member Dec 1, 2013
Lillian Mutava Individual Corporate OfficerBoard Member Aug 31, 2015

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Premier Community Health Care Group IncNew Port Richey, FL, CCN 101042 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Jul 1, 2009
Premier Community Health Care Group IncZephyrhills, FL, CCN 681144 Federally qualified health center Operational/Managerial Control (100%) Apr 1, 2019

Owned or controlled facilities with NPI records 2

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 79

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 79

NPI Registry JSON

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

{
    "created_epoch": "1139270400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1570579200000",
    "number": "1841263399",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 232",
            "city": "DADE CITY",
            "state": "FL",
            "postal_code": "335260232",
            "telephone_number": "352-518-2000",
            "fax_number": "352-567-1974"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "14027 5TH ST",
            "city": "DADE CITY",
            "state": "FL",
            "postal_code": "335254302",
            "telephone_number": "352-518-2000",
            "fax_number": "352-567-0218"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PREMIER COMMUNITY HEALTHCARE GROUP INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-02-07",
        "last_updated": "2019-10-09",
        "status": "A",
        "authorized_official_last_name": "MAFFETT",
        "authorized_official_first_name": "JENNIFER",
        "authorized_official_title_or_position": "HEALTH DATA ANALYST",
        "authorized_official_telephone_number": "352-518-2000"
    },
    "taxonomies": [
        {
            "code": "208D00000X",
            "taxonomy_group": "",
            "desc": "General Practice",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "029550700",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Dade City, FL

Sources for this page

Verify at the official NPI Registry.