Provider Demographics
NPI:1326202367
Name:PREMISE HEALTH OF CONNECTICUT MEDICAL, P.C.
Entity Type:Organization
Organization Name:PREMISE HEALTH OF CONNECTICUT MEDICAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:LEIZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-479-9063
Mailing Address - Street 1:40 BURTON HILLS BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-6155
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53172-2013
Practice Address - Country:US
Practice Address - Phone:414-768-4444
Practice Address - Fax:414-768-4782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-17
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty