=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558767244
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMISE HEALTH OF OHIO MEDICAL, P.A
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2014
-----------------------------------------------------
Last Update Date | 08/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 TECHNOLOGY DR
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63368-2239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-261-1600
-----------------------------------------------------
Fax | 636-261-1601
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5500 MARYLAND WAY
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-4948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-261-1600
-----------------------------------------------------
Fax | 636-261-1601
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JON LEIZMMAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 216-479-9063
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------