MEDICARE: PREMISE HEALTH OF TEXAS MEDICAL, P.A

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	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0069HJ	OTHER	TX	PRACTICE BCBS NUMBER

General Provider Information

NPI Number	:	1750456000
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMISE HEALTH OF TEXAS MEDICAL, P.A

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	:	HWY 31 WEST FM206
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75709
Country	:	US
Telephone Number	:	903-592-3257
Fax Number	:	903-592-3447

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JON LEIZMAN
Credential	:	M.D.
Telephone Number	:	216-479-9063

Provider Enumeration Date	:	11/22/2006
Last Update Date	:	08/23/2022

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Directions to “PREMISE HEALTH OF TEXAS MEDICAL, P.A ” Practice Location

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