Healthcare Provider Details

I. General information

NPI: 1861838450
Provider Name (Legal Business Name): PREMISE HEALTH OF MINNESOTA MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2013
Last Update Date: 08/16/2023
Certification Date: 08/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 7TH AVE S
SAINT CLOUD MN
56301-4213
US

IV. Provider business mailing address

5500 MARYLAND WAY
BRENTWOOD TN
37027-4948
US

V. Phone/Fax

Practice location:
  • Phone: 302-534-4687
  • Fax:
Mailing address:
  • Phone: 888-830-4255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

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