1700276169 NPI number — PREMISE HEALTH OF TENNESSEE MEDICAL, P.C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700276169 NPI number — PREMISE HEALTH OF TENNESSEE MEDICAL, P.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMISE HEALTH OF TENNESSEE MEDICAL, P.C
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700276169
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5500 MARYLAND WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-4948
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-261-8195
Provider Business Mailing Address Fax Number:
901-261-8196

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3145 PLAYERS CLUB PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38125-8835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-261-8195
Provider Business Practice Location Address Fax Number:
901-261-8196
Provider Enumeration Date:
01/23/2015

Additional Information

Authorized Official

Authorized Official Last Name:
LEIZMAN
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
216-479-9063

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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