Healthcare Provider Details

I. General information

NPI: 1760084156
Provider Name (Legal Business Name): PREMIER PEDIATRICS OF INDIANA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2020
Last Update Date: 07/20/2021
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 FLORENCE AVE STE 233
GRANGER IN
46530-8048
US

IV. Provider business mailing address

229 FLORENCE AVE STE 233
GRANGER IN
46530-8048
US

V. Phone/Fax

Practice location:
  • Phone: 574-855-4575
  • Fax:
Mailing address:
  • Phone: 574-855-4575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: CHARISSE JOHNSON
Title or Position: SOLE PROPRIETOR
Credential: MD
Phone: 317-345-3142