Healthcare Provider Details

I. General information

NPI: 1992148241
Provider Name (Legal Business Name): PREMISE HEALTH OF VIRGINIA MEDICAL, P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2013
Last Update Date: 08/15/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 CAPITAL ONE DR
MC LEAN VA
22102-3407
US

IV. Provider business mailing address

5500 MARYLAND WAY STE 120
BRENTWOOD TN
37027-4993
US

V. Phone/Fax

Practice location:
  • Phone: 703-720-1290
  • Fax: 703-720-1291
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JONATHAN B LEIZMAN
Title or Position: PRESIDENT
Credential: MD
Phone: 844-407-7557