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General NPI Number Information
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NPI Number | 1407177272
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Entity Type | Organization
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Legal Business Name | PREMISE HEALTH OF NEW YORK MEDICAL, P.C
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Dates
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Enumeration Date | 06/16/2010
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Last Update Date | 08/15/2022
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Provider Practice Location Address
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Address Line | 1585 BROADWAY 8TH FLOOR
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City | NEW YORK
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State | NY
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Zip | 10036-8200
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Country | US
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Telephone | 212-761-7989
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Fax |
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Provider Business Mailing Address
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Address Line | 1585 BROADWAY 8TH FLOOR
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City | NEW YORK
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State | NY
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Zip | 10036-8200
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Country | US
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Telephone | 212-761-7989
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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 | PA-C
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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 | 261QC1800X
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Taxonomy Name | Corporate Health Clinic/Center
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License Number | 008673
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License Number State | NY
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