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General NPI Number Information
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NPI Number | 1922383744
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Entity Type | Organization
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Legal Business Name | PREMISE HEALTH OF CONNECTICUT MEDICAL, P.C.
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Dates
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Enumeration Date | 10/12/2011
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Last Update Date | 08/15/2022
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Provider Practice Location Address
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Address Line | 426 E SOMO AVE
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City | TOMAHAWK
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State | WI
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Zip | 54487-1536
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Country | US
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Telephone | 715-453-1768
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Fax | 715-453-0540
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Provider Business Mailing Address
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Address Line | 1690616906 COLLECTIONS CTR DR
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City | CHICAGO
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State | IL
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Zip | 60693-0169
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Country | US
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Telephone | 715-453-1768
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Fax | 715-453-0540
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Authorized Official
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Title or Position | PRESIDENT
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Name | JON LEIZMAN
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Credential | M.D.
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Telephone | 216-479-9063
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QX0100X
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Taxonomy Name | Occupational Medicine Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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