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General NPI Number Information
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NPI Number | 1033494976
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Entity Type | Organization
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Legal Business Name | PREMISE HEALTH OF ILLINOIS MEDICAL, PC
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Dates
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Enumeration Date | 10/11/2011
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Last Update Date | 08/17/2023
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Provider Practice Location Address
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Address Line | 108 WILMOT RD
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City | DEERFIELD
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State | IL
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Zip | 60015-5145
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Country | US
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Telephone | 847-580-0002
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Fax | 847-374-0207
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Provider Business Mailing Address
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Address Line | 5500 MARYLAND WAY STE 120
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City | BRENTWOOD
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State | TN
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Zip | 37027-4993
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JON LEIZMAN
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Credential | MD
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Telephone | 216-479-9063
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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