Basic Information
| Provider Information | |||||||||
| NPI: | 1629132543 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMISE HEALTH OF LOUISANNA, PROFESSIONAL MEDICAL CORPORATION | ||||||||
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| OtherOrganizationName: | COUSHATTA FAMILY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5500 MARYLAND WAY STE 200 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370274973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164799063 | ||||||||
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| Practice Location | |||||||||
| Address1: | 121 TURKEY LANE | ||||||||
| Address2: | |||||||||
| City: | KINDER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3377384414 | ||||||||
| FaxNumber: | 3377387444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2006 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | LEIZMAN | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2164799063 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 08/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.