Provider Demographics
NPI:1114406295
Name:PREMISE HEALTH OF GEORGIA MEDICAL, P.C.
Entity Type:Organization
Organization Name:PREMISE HEALTH OF GEORGIA MEDICAL, P.C.
Other - Org Name:ROTARY EMPLOYEE HEALTH & WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:LEIZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-479-9063
Mailing Address - Street 1:5500 MARYLAND WAY STE 400
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7048
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 W BARNARD ST
Practice Address - Street 2:
Practice Address - City:GLENNVILLE
Practice Address - State:GA
Practice Address - Zip Code:30427-3030
Practice Address - Country:US
Practice Address - Phone:912-654-2694
Practice Address - Fax:912-654-2695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-09
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care