Healthcare Provider Details

I. General information

NPI: 1760962096
Provider Name (Legal Business Name): PREMISE HEALTH OF TEXAS MEDICAL, P.A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2018
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14355 MORRIS DIDO RD
NEWARK TX
76071-9501
US

IV. Provider business mailing address

5500 MARYLAND WAY STE 400
BRENTWOOD TN
37027-7048
US

V. Phone/Fax

Practice location:
  • Phone: 817-252-3680
  • Fax: 817-585-4323
Mailing address:
  • Phone:
  • 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. JON LEIZMAN
Title or Position: PRESIDENT
Credential: MD
Phone: 216-479-9063