Organization
PREMIER PEDIATRIC GROUP INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. BRADLEY JACKSON M.D. (OWNER)
(513) 770-3466
Entity
Organization
Contact information
Practice address
5386 COX SMITH ROAD, SUITE A, MASON, OH 45040
(513) 770-3466
(513) 770-3467
Mailing address
PO BOX 635228, CINCINNATI, OH 45263-0043
(513) 770-3466
(513) 770-3467
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2426771
—
OH
01
—
7200478
AETNA FOR ELIGABILITY
OH
Enumeration date
05/17/2007
Last updated
08/22/2020
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