Basic Information
| Provider Information | |||||||||
| NPI: | 1518204650 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMISE HEALTH OF ILLINOIS MEDICAL, S.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UNITED AIRLINES ONSITE ORD CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5500 MARYLAND WAY | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370274948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888304255 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11601 W TOUHY AVE | ||||||||
| Address2: | O'HARE INTERNATIONAL AIRPORT- TERMINAL 2- LOWER LEVEL | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606665047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706012525 | ||||||||
| FaxNumber: | 7706012533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2013 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | LEIZMAN | ||||||||
| AuthorizedOfficialFirstName: | JON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2164799063 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine |
No ID Information.