MEDICARE: PREMISE HEALTH OF OKLAHOMA 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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1538767363
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMISE HEALTH OF OKLAHOMA MEDICAL, P.C

Provider Business Mailing Address
First Line	:	5500 MARYLAND WAY STE 120
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-4993
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5460 MAIN ST STE 102
Second Line	:
City	:	DEL CITY
State	:	OK
Zip	:	73115-5525
Country	:	US
Telephone Number	:	615-468-3188
Fax Number	:	405-610-3431

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

Provider Enumeration Date	:	10/14/2020
Last Update Date	:	10/13/2022

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