Provider Demographics
NPI:1376820423
Name:PREMISE HEALTH OF WEST VIRGINIA MEDICAL, MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PREMISE HEALTH OF WEST VIRGINIA MEDICAL, MEDICAL CORPORATION
Other - Org Name:TOYOTA FAMILY HEALTH CENTER @ GEORGETOWN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:LEIZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:844-407-7557
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 1:1001 CHERRY BLOSSOM WAY
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-9564
Practice Address - Country:US
Practice Address - Phone:502-868-2894
Practice Address - Fax:502-868-4446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-03
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine