Basic Information
| Provider Information | |||||||||
| NPI: | 1255487096 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMISE HEALTH OF NORTH CAROLINA MEDICAL, P.C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16526 NC HIGHWAY 87 W | ||||||||
| Address2: | |||||||||
| City: | TAR HEEL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283928608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9108725710 | ||||||||
| FaxNumber: | 9108725711 | ||||||||
| Practice Location | |||||||||
| Address1: | 16526 NC HIGHWAY 87 W | ||||||||
| Address2: | |||||||||
| City: | TAR HEEL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283928608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9108725710 | ||||||||
| FaxNumber: | 9108725711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 08/24/2022 | ||||||||
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| AuthorizedOfficialLastName: | LEIZMAN | ||||||||
| AuthorizedOfficialFirstName: | JON | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2164799063 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| NPICertificationDate: | 08/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 08321 | NC | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 08321 | 01 | NC | NC PHARMACY PERMIT | OTHER |