Provider Demographics
NPI:1093397978
Name:PREMISE HEALTH OF MONTANA MEDICAL P C
Entity Type:Organization
Organization Name:PREMISE HEALTH OF MONTANA MEDICAL P C
Other - Org Name:MONTANA ANACONDA HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEIZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-479-9063
Mailing Address - Street 1:5500 MARYLAND WAY STE 120
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4993
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:602 E PARK AVE
Practice Address - Street 2:
Practice Address - City:ANACONDA
Practice Address - State:MT
Practice Address - Zip Code:59711-2469
Practice Address - Country:US
Practice Address - Phone:406-384-7630
Practice Address - Fax:406-384-7374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-21
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty