Provider Demographics
NPI:1558700013
Name:PREMISE HEALTH OF CONNECTICUT MEDICAL, P.C.
Entity Type:Organization
Organization Name:PREMISE HEALTH OF CONNECTICUT MEDICAL, P.C.
Other - Org Name:FIDELITY HEALTH & WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:LEIZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-479-9063
Mailing Address - Street 1:5500 MARYLAND WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4948
Mailing Address - Country:US
Mailing Address - Phone:603-791-5999
Mailing Address - Fax:603-578-7054
Practice Address - Street 1:1 SPARTAN WAY
Practice Address - Street 2:MAILZONE TS3N
Practice Address - City:MERRIMACK
Practice Address - State:NH
Practice Address - Zip Code:03054-4300
Practice Address - Country:US
Practice Address - Phone:603-791-5999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-18
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care