Provider Demographics
NPI:1205300159
Name:PREMISE HEALTH OF ILLINOIS MEDICAL, PC
Entity type:Organization
Organization Name:PREMISE HEALTH OF ILLINOIS MEDICAL, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:615-468-6270
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 1:108 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MT STERLING
Practice Address - State:IL
Practice Address - Zip Code:62353-1224
Practice Address - Country:US
Practice Address - Phone:217-773-6060
Practice Address - Fax:217-436-6762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-14
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care