Healthcare Provider Details

I. General information

NPI: 1063770196
Provider Name (Legal Business Name): PREMISE HEALTH OF OHIO MEDICAL, P.A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2012
Last Update Date: 08/16/2022
Certification Date: 08/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3925 159TH AVE NE
REDMOND WA
98052-6309
US

IV. Provider business mailing address

5500 MARYLAND WAY
BRENTWOOD TN
37027-4948
US

V. Phone/Fax

Practice location:
  • Phone: 425-216-0550
  • Fax: 425-216-0551
Mailing address:
  • Phone: 877-865-9013
  • Fax: 425-216-0551

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: JON LEIZMAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 216-479-9063