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General NPI Number Information
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NPI Number | 1841562808
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Entity Type | Organization
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Legal Business Name | PREMISE HEALTH OF FLORIDA MEDICAL, P.A.
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Dates
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Enumeration Date | 02/06/2012
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Last Update Date | 08/15/2022
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Provider Practice Location Address
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Address Line | 494 N WASHINGTON AVE
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City | TITUSVILLE
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State | FL
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Zip | 32796-2871
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Country | US
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Telephone | 321-267-8311
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Fax | 321-267-2881
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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 | 877-865-9013
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Fax | 321-267-2881
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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 | 261QX0100X
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Taxonomy Name | Occupational Medicine Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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