Healthcare Provider Details

I. General information

NPI: 1225397227
Provider Name (Legal Business Name): PREMISE HEALTH OF ARIZONA MEDICAL, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2012
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W JEFFERSON ST STE 201
PHOENIX AZ
85003-2195
US

IV. Provider business mailing address

16906 COLLECTION CENTER DR
CHICAGO IL
60693-0169
US

V. Phone/Fax

Practice location:
  • Phone: 480-347-4791
  • Fax: 480-347-4792
Mailing address:
  • Phone: 877-865-9013
  • Fax: 480-347-4792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JON LEIZMAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 216-479-9063