Healthcare Provider Details

I. General information

NPI: 1407910169
Provider Name (Legal Business Name): PREMISE HEALTH OF GEORGIA MEDICAL, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 EAST 65TH STREET, 4 MEDICAL ARTS
SAVANNAH GA
31405-4491
US

IV. Provider business mailing address

16906 COLLECTION CENTER DR
CHICAGO IL
60693-0169
US

V. Phone/Fax

Practice location:
  • Phone: 912-351-0057
  • Fax: 912-351-0074
Mailing address:
  • Phone: 877-865-9013
  • Fax: 217-709-2345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JON LEIZMAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 216-479-9603