Provider Demographics
NPI:1437213394
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:EVERGREEN PACKAGING FAMILY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
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
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4948
Mailing Address - Country:US
Mailing Address - Phone:877-865-9013
Mailing Address - Fax:217-709-2345
Practice Address - Street 1:119 PARK ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NC
Practice Address - Zip Code:28716-4319
Practice Address - Country:US
Practice Address - Phone:828-235-3023
Practice Address - Fax:828-235-9119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2338949Medicare PIN