Healthcare Provider Details

I. General information

NPI: 1518650035
Provider Name (Legal Business Name): PREMISE HEALTH OF PENNSYLVANIA MEDICAL, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2023
Last Update Date: 05/31/2023
Certification Date: 05/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MYLAN BLVD
CANONSBURG PA
15317-5853
US

IV. Provider business mailing address

5500 MARYLAND WAY STE 120
BRENTWOOD TN
37027-4993
US

V. Phone/Fax

Practice location:
  • Phone: 304-554-5298
  • Fax: 304-462-2447
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: MD
Phone: 615-468-6270