Healthcare Provider Details

I. General information

NPI: 1073748059
Provider Name (Legal Business Name): PREMISE HEALTH OF OHIO MEDICAL, P.A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2009
Last Update Date: 08/16/2022
Certification Date: 08/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 S VAN BUREN AVE
BARBERTON OH
44203-3543
US

IV. Provider business mailing address

5500 MARYLAND WAY SUITE 400
BRENTWOOD TN
37027-7048
US

V. Phone/Fax

Practice location:
  • Phone: 330-745-4812
  • Fax:
Mailing address:
  • Phone: 888-830-4255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JON LEIZMAN
Title or Position: PRESIDENT
Credential: MD
Phone: 216-479-9063