MEDICARE: PREMISE HEALTH OF INDIANA MEDICAL PC

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	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1447955406
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMISE HEALTH OF INDIANA MEDICAL PC

Provider Business Mailing Address
First Line	:	5500 MARYLAND WAY
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-7048
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10006 AUBURN PARK DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-2389
Country	:	US
Telephone Number	:	260-247-8020
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	EDWARD WILLIAM SCHWARTZ
Credential	:
Telephone Number	:	844-407-7557

Provider Enumeration Date	:	03/31/2023
Last Update Date	:	02/04/2026

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