MEDICARE: PREMISE HEALTH OF CONNECTICUT MEDICAL, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor

General Provider Information

NPI Number	:	1326202367
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMISE HEALTH OF CONNECTICUT MEDICAL, P.C.

Provider Business Mailing Address
First Line	:	40 BURTON HILLS BLVD
Second Line	:	SUITE 200
City	:	NASHVILLE
State	:	TN
Zip	:	37215-6155
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1100 MILWAUKEE AVE
Second Line	:
City	:	SOUTH MILWAUKEE
State	:	WI
Zip	:	53172-2013
Country	:	US
Telephone Number	:	414-768-4444
Fax Number	:	414-768-4782

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JON LEIZMAN
Credential	:
Telephone Number	:	216-479-9063

Provider Enumeration Date	:	07/17/2008
Last Update Date	:	08/15/2022

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