Provider Demographics
NPI:1992096978
Name:PREMISE HEALTH OF DELAWARE MEDICAL, P.A.
Entity type:Organization
Organization Name:PREMISE HEALTH OF DELAWARE MEDICAL, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
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 1:16906 COLLECTION CENTER DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60693-1307
Mailing Address - Country:US
Mailing Address - Phone:302-286-4012
Mailing Address - Fax:302-286-3248
Practice Address - Street 1:587 OLD BALTIMORE PIKE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702-1307
Practice Address - Country:US
Practice Address - Phone:302-286-4012
Practice Address - Fax:302-286-3248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-26
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care