Provider Demographics
NPI:1427112648
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:PC OWNER
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 1:40 BURTON HILLS BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-6155
Mailing Address - Country:US
Mailing Address - Phone:615-565-1733
Mailing Address - Fax:615-296-0151
Practice Address - Street 1:406 E HALL OF FAME AVE
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74075-5428
Practice Address - Country:US
Practice Address - Phone:800-370-1192
Practice Address - Fax:405-707-3015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER