MEDICARE: PREMISE HEALTH OF ILLINOIS MEDICAL, PC

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	261QX0100X	Occupational Medicine Clinic/Center

General Provider Information

NPI Number	:	1518204650
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMISE HEALTH OF ILLINOIS MEDICAL, PC

Provider Business Mailing Address
First Line	:	5500 MARYLAND WAY
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-4948
Country	:	US
Telephone Number	:	888-830-4255
Fax Number	:

Provider Business Practice Location Address
First Line	:	11601 W TOUHY AVE
Second Line	:	O'HARE INTERNATIONAL AIRPORT- TERMINAL 2- LOWER LEVEL
City	:	CHICAGO
State	:	IL
Zip	:	60666-5047
Country	:	US
Telephone Number	:	770-601-2525
Fax Number	:	770-601-2533

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JON LEIZMAN
Credential	:	MD
Telephone Number	:	615-468-6270

Provider Enumeration Date	:	01/09/2013
Last Update Date	:	08/21/2023

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