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General NPI Number Information
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NPI Number | 1932794112
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Entity Type | Organization
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Legal Business Name | PREMISE HEALTH OF WEST VIRGINIA MEDICAL, MEDICAL CORPORATION
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Dates
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Enumeration Date | 03/09/2021
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Last Update Date | 08/15/2022
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Provider Practice Location Address
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Address Line | 601 MORRIS ST STE 203
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City | CHARLESTON
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State | WV
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Zip | 25301-1416
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Country | US
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Telephone | 681-205-8538
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Fax | 681-205-8546
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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 | DR. JONATHAN B LEIZMAN
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Credential | MD
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Telephone | 844-407-7557
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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