Provider Demographics
NPI:1740540327
Name:PREMISE HEALTH OF OKLAHOMA MEDICAL, P.C
Entity type:Organization
Organization Name:PREMISE HEALTH OF OKLAHOMA MEDICAL, P.C
Other - Org Name:<UNAVAIL>
Other - Org Type:
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
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:580-224-8750
Mailing Address - Fax:580-224-8751
Practice Address - Street 1:1105 MICHELIN RD
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1085
Practice Address - Country:US
Practice Address - Phone:580-224-8750
Practice Address - Fax:580-224-8751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-17
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center