Provider Demographics
NPI:1497274013
Name:PREMISE HEALTH OF MARYLAND MEDICAL P C
Entity Type:Organization
Organization Name:PREMISE HEALTH OF MARYLAND MEDICAL P C
Other - Org Name:THE WELLNESS CENTER OPERATED BY PREMISE HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:THIEL
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 1:103 CHESAPEAKE PARK PLZ
Practice Address - Street 2:
Practice Address - City:MIDDLE RIVER
Practice Address - State:MD
Practice Address - Zip Code:21220-4201
Practice Address - Country:US
Practice Address - Phone:410-682-1609
Practice Address - Fax:410-682-1458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-14
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center