Healthcare Provider Details

I. General information

NPI: 1376820423
Provider Name (Legal Business Name): PREMISE HEALTH OF WEST VIRGINIA MEDICAL, MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2011
Last Update Date: 08/15/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 CHERRY BLOSSOM WAY
GEORGETOWN KY
40324-9564
US

IV. Provider business mailing address

5500 MARYLAND WAY STE 120
BRENTWOOD TN
37027-4993
US

V. Phone/Fax

Practice location:
  • Phone: 502-868-2894
  • Fax: 502-868-4446
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JONATHAN B LEIZMAN
Title or Position: PRESIDENT/CHIEF MEDICAL OFFICER
Credential: MD
Phone: 844-407-7557