MEDICARE: PREMISE HEALTH OF NORTH CAROLINA MEDICAL, P.C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1407259203
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMISE HEALTH OF NORTH CAROLINA MEDICAL, P.C

Provider Business Mailing Address
First Line	:	5500 MARYLAND WAY
Second Line	:	STE 200
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-4948
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5500 MARYLAND WAY
Second Line	:	STE 200
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-4948
Country	:	US
Telephone Number	:	615-577-4927
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JONATHAN LEIZMAN
Credential	:
Telephone Number	:	216-479-9063

Provider Enumeration Date	:	10/07/2014
Last Update Date	:	10/13/2022

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