| Entity Name: | PREMIER OB/GYN, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 19 Jun 2013 (12 years ago) |
| Last Event: | LC STMNT OF RA/RO CHG |
| Event Date Filed: | 15 Dec 2023 (a year ago) |
| Document Number: | L13000088479 |
| FEI/EIN Number | 61-1719071 |
| Address: | 4010 W. Boy Scout Blvd, Suite 500, Tampa, FL 33607 |
| Mail Address: | 4010 W. Boy Scout Blvd, Suite 500, Tampa, FL 33607 |
| ZIP code: | 33607 |
| County: | Hillsborough |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1174663694 | 2007-02-07 | 2012-01-04 | 2727 W DR MLK JR BLVD, SUITE 630, TAMPA, FL, 33607, US | 2727 W DR MARTIN LUTHER KING JR BLVD, SUITE 630, TAMPA, FL, 336076383, US | |||||||||||||||||||||||||
|
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| Phone | +1 813-876-6000 |
| Fax | 8138760590 |
Authorized person
| Name | VICKIE L GONZALEZ |
| Role | OFFICE MANAGER |
| Phone | 8138766000 |
Taxonomy
| Taxonomy Code | 207V00000X - Obstetrics & Gynecology Physician |
| License Number | ME 43544 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 0615498 |
| State | FL |
| Name | Role |
|---|---|
| CORPORATION SERVICE COMPANY | Agent |
| Name | Role | Address |
|---|---|---|
| Wright, Brian | Chief Legal Officer | 4010 W. Boy Scout Blvd, Suite 500 Tampa, FL 33607 |
| Name | Role |
|---|---|
| FLORIDA WOMAN CARE, LLC | Member |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G22000160373 | IN A WOMAN'S IMAGE | ACTIVE | 2022-12-28 | 2027-12-31 | No data | 5323 4TH AVENUE CIRCLE EAST, BRADENTON, FL, 34208 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-09-17 | 4010 W. Boy Scout Blvd, Suite 500, Tampa, FL 33607 | No data |
| CHANGE OF MAILING ADDRESS | 2024-09-17 | 4010 W. Boy Scout Blvd, Suite 500, Tampa, FL 33607 | No data |
| LC STMNT OF RA/RO CHG | 2023-12-15 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2023-12-15 | CORPORATION SERVICE COMPANY | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2023-12-15 | 1201 HAYS STREET, TALLAHASSEE, FL 32301-2525 | No data |
| Name | Date |
|---|---|
| AMENDED ANNUAL REPORT | 2024-09-17 |
| ANNUAL REPORT | 2024-04-09 |
| CORLCRACHG | 2023-12-15 |
| ANNUAL REPORT | 2023-03-06 |
| ANNUAL REPORT | 2022-02-18 |
| ANNUAL REPORT | 2021-04-15 |
| ANNUAL REPORT | 2020-01-28 |
| ANNUAL REPORT | 2019-03-27 |
| ANNUAL REPORT | 2018-04-19 |
| ANNUAL REPORT | 2017-03-21 |
Date of last update: 22 Jan 2025
Sources: Florida Department of State
