Healthcare Provider Details

I. General information

NPI: 1700017795
Provider Name (Legal Business Name): PREMISE HEALTH OF NEW JERSEY MEDICAL, P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2009
Last Update Date: 08/15/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 PACIFIC AVE
ATLANTIC CITY NJ
08401-6726
US

IV. Provider business mailing address

5500 MARYLAND WAY
BRENTWOOD TN
37027-4948
US

V. Phone/Fax

Practice location:
  • Phone: 609-340-1633
  • Fax: 609-340-1230
Mailing address:
  • Phone: 888-830-4255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JONATHAN LEIZMAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 216-479-9063