Healthcare Provider Details

I. General information

NPI: 1235509167
Provider Name (Legal Business Name): PREMISE HEALTH OF INDIANA MEDICAL, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2015
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 JACKSON ST
COLUMBUS IN
47201-6264
US

IV. Provider business mailing address

5500 MARYLAND WAY STE 120
BRENTWOOD TN
37027-4993
US

V. Phone/Fax

Practice location:
  • Phone: 812-748-3412
  • Fax: 812-748-3413
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

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