MEDICARE: PREMISE HEALTH OF WEST VIRGINIA MEDICAL, MEDICAL CORPORATION

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	:	1306089560
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMISE HEALTH OF WEST VIRGINIA MEDICAL, MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	5500 MARYLAND WAY
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-4948
Country	:	US
Telephone Number	:	913-315-6432
Fax Number	:	913-461-2574

Provider Business Practice Location Address
First Line	:	6400 SPRINT PKWY
Second Line	:	MAILSTOP KSOPHG0202
City	:	OVERLAND PARK
State	:	KS
Zip	:	66251-6107
Country	:	US
Telephone Number	:	913-315-6432
Fax Number	:	913-461-2574

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

Provider Enumeration Date	:	04/16/2009
Last Update Date	:	08/15/2022

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