Healthcare Provider Details

I. General information

NPI: 1518204650
Provider Name (Legal Business Name): PREMISE HEALTH OF ILLINOIS MEDICAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2013
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11601 W TOUHY AVE O'HARE INTERNATIONAL AIRPORT- TERMINAL 2- LOWER LEVEL
CHICAGO IL
60666-5047
US

IV. Provider business mailing address

5500 MARYLAND WAY
BRENTWOOD TN
37027-4948
US

V. Phone/Fax

Practice location:
  • Phone: 770-601-2525
  • Fax: 770-601-2533
Mailing address:
  • Phone: 888-830-4255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JON LEIZMAN
Title or Position: PRESIDENT
Credential: MD
Phone: 615-468-6270