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General NPI Number Information
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NPI Number | 1467648907
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Entity Type | Organization
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Legal Business Name | PREMISE HEALTH OF INDIANA MEDICAL, P.C.
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Dates
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Enumeration Date | 09/19/2007
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Last Update Date | 08/25/2022
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Provider Practice Location Address
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Address Line | 806 JACKSON ST
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City | COLUMBUS
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State | IN
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Zip | 47201-6264
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Country | US
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Telephone | 812-377-6020
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Fax | 812-377-6024
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Provider Business Mailing Address
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Address Line | 5500 MARYLAND WAY
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City | BRENTWOOD
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State | TN
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Zip | 37027-4948
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Country | US
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Telephone | 877-865-9001
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Fax | 217-709-2345
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Authorized Official
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Title or Position | PRESIDENT
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Name | JON LEIZMAN
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Credential | M.D.
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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 | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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