MEDICARE: PREMISE HEALTH OF COLORADO 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	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1952974396
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMISE HEALTH OF COLORADO MEDICAL, P.C.

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

Provider Business Practice Location Address
First Line	:	11860 PECOS ST
Second Line	:
City	:	WESTMINSTER
State	:	CO
Zip	:	80234-2740
Country	:	US
Telephone Number	:	864-402-8220
Fax Number	:

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

Provider Enumeration Date	:	07/22/2021
Last Update Date	:	08/23/2022

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