Healthcare Provider Details

I. General information

NPI: 1093482002
Provider Name (Legal Business Name): PREMISE HEALTH OF ILLINOIS MEDICAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2021
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 W WACKER DR
CHICAGO IL
60606-1220
US

IV. Provider business mailing address

5500 MARYLAND WAY
BRENTWOOD TN
37027-7048
US

V. Phone/Fax

Practice location:
  • Phone: 615-468-3188
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

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