Healthcare Provider Details

I. General information

NPI: 1922383744
Provider Name (Legal Business Name): PREMISE HEALTH OF CONNECTICUT MEDICAL, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2011
Last Update Date: 08/15/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 E SOMO AVE
TOMAHAWK WI
54487-1536
US

IV. Provider business mailing address

1690616906 COLLECTIONS CTR DR
CHICAGO IL
60693-0169
US

V. Phone/Fax

Practice location:
  • Phone: 715-453-1768
  • Fax: 715-453-0540
Mailing address:
  • Phone: 715-453-1768
  • Fax: 715-453-0540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JON LEIZMAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 216-479-9063