Healthcare Provider Details

I. General information

NPI: 1700202819
Provider Name (Legal Business Name): PREMISE HEALTH OF SOUTH CAROLINA MEDICAL, P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2014
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2480 TWO NOTCH RD
LEXINGTON SC
29072-7963
US

IV. Provider business mailing address

5500 MARYLAND WAY
BRENTWOOD TN
37027-4948
US

V. Phone/Fax

Practice location:
  • Phone: 803-951-5871
  • Fax: 803-951-5872
Mailing address:
  • Phone: 888-830-4255
  • 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 LEIZMAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 216-479-9063