Provider Demographics
NPI:1255487096
Name:PREMISE HEALTH OF NORTH CAROLINA MEDICAL, P.C
Entity Type:Organization
Organization Name:PREMISE HEALTH OF NORTH CAROLINA MEDICAL, P.C
Other - Org Name:
Other - Org Type:
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:
Authorized Official - Phone:216-479-9063
Mailing Address - Street 1:16526 NC HIGHWAY 87 W
Mailing Address - Street 2:
Mailing Address - City:TAR HEEL
Mailing Address - State:NC
Mailing Address - Zip Code:28392-8608
Mailing Address - Country:US
Mailing Address - Phone:910-872-5710
Mailing Address - Fax:910-872-5711
Practice Address - Street 1:16526 NC HIGHWAY 87 W
Practice Address - Street 2:
Practice Address - City:TAR HEEL
Practice Address - State:NC
Practice Address - Zip Code:28392-8608
Practice Address - Country:US
Practice Address - Phone:910-872-5710
Practice Address - Fax:910-872-5711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC08321261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC08321OtherNC PHARMACY PERMIT