Provider Demographics
NPI:1538561832
Name:PREMISE HEALTH OF CONNECTICUT MEDICAL, P.C.
Entity type:Organization
Organization Name:PREMISE HEALTH OF CONNECTICUT MEDICAL, P.C.
Other - Org Name:<UNAVAIL>
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: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:203-588-8275
Mailing Address - Fax:203-588-6524
Practice Address - Street 1:201 TRESSER BLVD BLDG LOBBY
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06901-3432
Practice Address - Country:US
Practice Address - Phone:203-588-8275
Practice Address - Fax:203-588-6524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-18
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty