Provider Demographics
NPI:1316090665
Name:PREMISE HEALTH OF VERMONT MEDICAL PC
Entity type:Organization
Organization Name:PREMISE HEALTH OF VERMONT MEDICAL PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
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 1:110 LAKE ST
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-2266
Practice Address - Country:US
Practice Address - Phone:802-524-8505
Practice Address - Fax:802-527-2807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420008643261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN0373Medicaid
VTF28051Medicare UPIN