Provider Demographics
NPI:1407910169
Name:PREMISE HEALTH OF GEORGIA MEDICAL, P.C.
Entity Type:Organization
Organization Name:PREMISE HEALTH OF GEORGIA MEDICAL, P.C.
Other - Org Name:EMPLOYEES' FAMILY MEDICAL 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:216-479-9603
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:217-709-2345
Practice Address - Street 1:836 EAST 65TH STREET, 4 MEDICAL ARTS
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4491
Practice Address - Country:US
Practice Address - Phone:912-351-0057
Practice Address - Fax:912-351-0074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA8892OtherGROUP BCBS NUMBER
GAGRP6866Medicare PIN