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General NPI Number Information
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NPI Number | 1710644075
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Entity Type | Organization
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Legal Business Name | PREMISE HEALTH OF WISCONSIN MEDICAL S C
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Dates
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Enumeration Date | 11/22/2021
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Last Update Date | 10/13/2022
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Provider Practice Location Address
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Address Line | 318 N 6TH ST
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City | TOMAHAWK
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State | WI
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Zip | 54487-1423
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Country | US
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Telephone | 715-436-5066
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Fax | 715-425-5848
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Provider Business Mailing Address
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Address Line | 5500 MARYLAND WAY STE 120
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City | BRENTWOOD
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State | TN
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Zip | 37027-4993
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JONATHAN LEIZMAN
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Credential |
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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 | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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