Healthcare Provider Details

I. General information

NPI: 1942363841
Provider Name (Legal Business Name): PREMISE HEALTH OF INDIANA MEDICAL, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2022 KELLE DR
CHESTERTON IN
46304-8708
US

IV. Provider business mailing address

5500 MARYLAND WAY STE 120
BRENTWOOD TN
37027-4993
US

V. Phone/Fax

Practice location:
  • Phone: 219-395-2200
  • Fax: 219-983-1837
Mailing address:
  • Phone: 216-479-9063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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