Basic Information
| Provider Information | |||||||||
| NPI: | 1891207536 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMISE HEALTH OF GEORGIA MEDICAL, P.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HARRISON POULTRY WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5500 MARYLAND WAY STE 400 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8444077557 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 107 E STAR ST | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306202119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789753115 | ||||||||
| FaxNumber: | 6789753116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2017 | ||||||||
| 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. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.