MEDICARE: PREMISE HEALTH OF GEORGIA MEDICAL, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1073092169
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMISE HEALTH OF GEORGIA MEDICAL, P.C.

Provider Business Mailing Address
First Line	:	5500 MARYLAND WAY STE 400
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-7048
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	342 E BRAZELL ST
Second Line	:
City	:	REIDSVILLE
State	:	GA
Zip	:	30453-5046
Country	:	US
Telephone Number	:	912-557-1950
Fax Number	:	912-557-1953

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JON LEIZMAN
Credential	:	MD
Telephone Number	:	216-479-9063

Provider Enumeration Date	:	08/09/2018
Last Update Date	:	08/24/2022

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