=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639473499
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMISE HEALTH OF NORTH CAROLINA MEDICAL, P.C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2011
-----------------------------------------------------
Last Update Date | 08/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8500 ANDREW CARNEGIE BLVD MS D1/01
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28262-8500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-988-2572
-----------------------------------------------------
Fax | 704-988-4820
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5500 MARYLAND WAY STE 120
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-4993
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JON LEIZMAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 216-479-9063
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------