Healthcare Provider Details

I. General information

NPI: 1407108509
Provider Name (Legal Business Name): PREMISE HEALTH OF VIRGINIA MEDICAL, P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2012
Last Update Date: 08/15/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 BERMUDA HUNDRED RD
CHESTER VA
23836-3245
US

IV. Provider business mailing address

5500 MARYLAND WAY STE 400
BRENTWOOD TN
37027-4948
US

V. Phone/Fax

Practice location:
  • Phone: 804-751-1922
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

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