MEDICARE: PREMISE HEALTH OF WASHINGTON 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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1528345550
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMISE HEALTH OF WASHINGTON MEDICAL, P.C

Provider Business Mailing Address
First Line	:	5500 MARYLAND WAY
Second Line	:	SUITE 400
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-4948
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	747 6TH ST S
Second Line	:
City	:	KIRKLAND
State	:	WA
Zip	:	98033-6715
Country	:	US
Telephone Number	:	650-214-6369
Fax Number	:

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

Provider Enumeration Date	:	11/04/2011
Last Update Date	:	08/15/2022

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