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General NPI Number Information
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NPI Number | 1053838912
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Entity Type | Organization
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Legal Business Name | PREMISE HEALTH OF NORTH CAROLINA MEDICAL, P.C
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Dates
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Enumeration Date | 08/23/2017
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Last Update Date | 08/23/2023
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Provider Practice Location Address
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Address Line | 5501 JOSH BIRMINGHAM PKWY # B11B12
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City | CHARLOTTE
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State | NC
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Zip | 28208-5750
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Country | US
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Telephone | 704-343-5006
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Fax | 704-359-0900
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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 | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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