Provider Demographics
NPI:1679818140
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:FIDELITY HEALTH & WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:LEIZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-479-9063
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 1:100 MILLENNIUM WAY
Practice Address - Street 2:BUILDING 3, FIRST FLOOR
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27709-0158
Practice Address - Country:US
Practice Address - Phone:919-458-5500
Practice Address - Fax:919-458-3422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-10
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care