Healthcare Provider Details

I. General information

NPI: 1366997942
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: 08/24/2016
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 SULLIVAN WAY
EWING NJ
08628-3406
US

IV. Provider business mailing address

5500 MARYLAND WAY SUITE 400
BRENTWOOD TN
37027-7048
US

V. Phone/Fax

Practice location:
  • Phone: 609-883-1300
  • 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: JON B LEIZMAN
Title or Position: PRESIDENT
Credential: MD
Phone: 216-479-9063