Healthcare Provider Details

I. General information

NPI: 1619640562
Provider Name (Legal Business Name): PREMISE HEALTH OF MISSISSIPPI MEDICAL, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2021
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 FOUNTAIN DR
FOREST MS
39074-4038
US

IV. Provider business mailing address

5500 MARYLAND WAY
BRENTWOOD TN
37027-7048
US

V. Phone/Fax

Practice location:
  • Phone: 601-469-0234
  • 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: JONATHAN LEIZMAN
Title or Position: PRESIDENT
Credential:
Phone: 216-479-9063