MEDICARE: PREMISE HEALTH OF NORTH CAROLINA 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	:	1467931584
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMISE HEALTH OF NORTH CAROLINA 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	:	112 MEDICAL VILLAGE DR STE F
Second Line	:
City	:	WALLACE
State	:	NC
Zip	:	28466-1665
Country	:	US
Telephone Number	:	910-285-0940
Fax Number	:	910-285-1825

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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