Healthcare Provider Details

I. General information

NPI: 1134052053
Provider Name (Legal Business Name): PREMIER VILLAGE PHYSICIANS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12680 LONGLEAF LN
FISHERS IN
46038-9188
US

IV. Provider business mailing address

12680 LONGLEAF LN
FISHERS IN
46038-9188
US

V. Phone/Fax

Practice location:
  • Phone: 317-777-0628
  • Fax: 317-342-3117
Mailing address:
  • Phone: 317-777-0628
  • Fax: 317-342-3117

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: DR. TYLER VERNON
Title or Position: OWNER, CEO, PHYSICIAN
Credential: DO
Phone: 317-777-0628