Provider Demographics
NPI:1952465056
Name:PREMISE HEALTH OF GEORGIA MEDICAL, P.C.
Entity Type:Organization
Organization Name:PREMISE HEALTH OF GEORGIA MEDICAL, P.C.
Other - Org Name:FIELDALE FARMS FAMILY MEDICAL 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
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:844-407-7557
Mailing Address - Fax:
Practice Address - Street 1:184 PROFESSIONAL DR UNIT B
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:GA
Practice Address - Zip Code:30511-4012
Practice Address - Country:US
Practice Address - Phone:706-894-2714
Practice Address - Fax:706-894-2715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
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
GAGRP7430Medicare PIN