NPIMap

Organization Active NPI

Premise Health of Connecticut Medical, P.C.

Doing business as MTV Health Center

  • Primary Care Clinic/Center
  • Manassas, VA
National Provider Identifier
1598054793
Registry record updated Aug 15, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Clinic/CenterTaxonomy code 261QP2300X
Legal business name
PREMISE HEALTH OF CONNECTICUT MEDICAL, P.C.
Doing business as
MTV Health Center
Practice address
9600 Godwin Dr
Manassas, VA 20110-4162
Phone
(703) 396-1067
Fax
(703) 396-1060
NPI assigned
Mar 29, 2011
Last updated
Aug 15, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 15, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jon Leizman, MD
Title
President
Phone
(216) 479-9063

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Clinic/Center 261QP2300X NU Primary

Addresses

Primary practice location

9600 Godwin Dr
Manassas, VA 20110-4162

Mailing address

5500 Maryland Way
Brentwood, TN 37027-4948
Phone (703) 396-1067

Other names 1

  • MTV Health Center Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Premise Health of Connecticut Medical PC21 organizations share this tax ID, including this one

Other organizations with this tax ID 20

Organizations that report the same tax identification number in the National Provider Directory.

View all 20

Locations

9600 Godwin Dr
Manassas, VA 20110
Phone (703) 396-1064

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1301356800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1660521600000",
    "number": "1598054793",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5500 MARYLAND WAY",
            "city": "BRENTWOOD",
            "state": "TN",
            "postal_code": "370274948",
            "telephone_number": "703-396-1067",
            "fax_number": "703-396-1060"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9600 GODWIN DR",
            "city": "MANASSAS",
            "state": "VA",
            "postal_code": "201104162",
            "telephone_number": "703-396-1067",
            "fax_number": "703-396-1060"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PREMISE HEALTH OF CONNECTICUT MEDICAL, P.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-03-29",
        "last_updated": "2022-08-15",
        "certification_date": "2022-08-15",
        "status": "A",
        "authorized_official_last_name": "LEIZMAN",
        "authorized_official_first_name": "JON",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "216-479-9063",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "MTV Health Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "MTV Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Manassas, VA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 15, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.