Provider Demographics
NPI:1225397227
Name:PREMISE HEALTH OF ARIZONA MEDICAL, P.C.
Entity Type:Organization
Organization Name:PREMISE HEALTH OF ARIZONA MEDICAL, P.C.
Other - Org Name:MARICOPA HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
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 1:16906 COLLECTION CENTER DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60693-0169
Mailing Address - Country:US
Mailing Address - Phone:877-865-9013
Mailing Address - Fax:480-347-4792
Practice Address - Street 1:301 W JEFFERSON ST STE 201
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85003-2195
Practice Address - Country:US
Practice Address - Phone:480-347-4791
Practice Address - Fax:480-347-4792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-10
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine