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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1396334835
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 STE 120
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-4993
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3675 N BEND RD
Second Line	:
City	:	HEBRON
State	:	KY
Zip	:	41048-8465
Country	:	US
Telephone Number	:	859-334-7587
Fax Number	:

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

Provider Enumeration Date	:	01/11/2021
Last Update Date	:	08/15/2022

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