Healthcare Provider Details

I. General information

NPI: 1962232504
Provider Name (Legal Business Name): PREMISE HEALTH OF NORTH CAROLINA MEDICAL, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2024
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7033 LOUIS STEPHENS DR # F17Q
MORRISVILLE NC
27560-6399
US

IV. Provider business mailing address

5500 MARYLAND WAY STE 120
BRENTWOOD TN
37027-4993
US

V. Phone/Fax

Practice location:
  • Phone: 919-994-6331
  • Fax: 919-516-0612
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 B LEIZMAN
Title or Position: PRESIDENT
Credential:
Phone: 615-468-6270