=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588128656
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMISE HEALTH OF GEORGIA MEDICAL, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2019
-----------------------------------------------------
Last Update Date | 08/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2659 ABUTMENT RD
-----------------------------------------------------
City | DALTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30721-4887
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-532-6700
-----------------------------------------------------
Fax | 706-532-6760
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5500 MARYLAND WAY STE 200
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-4973
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JON LEIZMAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
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 |
-----------------------------------------------------