Provider Demographics
NPI:1629132543
Name:PREMISE HEALTH OF LOUISANNA, PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PREMISE HEALTH OF LOUISANNA, PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:COUSHATTA FAMILY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
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 STE 200
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4973
Mailing Address - Country:US
Mailing Address - Phone:216-479-9063
Mailing Address - Fax:
Practice Address - Street 1:121 TURKEY LANE
Practice Address - Street 2:
Practice Address - City:KINDER
Practice Address - State:LA
Practice Address - Zip Code:70648
Practice Address - Country:US
Practice Address - Phone:337-738-4414
Practice Address - Fax:337-738-7444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty