Healthcare Provider Details

I. General information

NPI: 1336751312
Provider Name (Legal Business Name): INDYSTATHEALTHEDU, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2020
Last Update Date: 04/26/2024
Certification Date: 04/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9465 COUNSELORS ROW STE 200
INDIANAPOLIS IN
46240-3817
US

IV. Provider business mailing address

9465 COUNSELORS ROW STE 200
INDIANAPOLIS IN
46240-3817
US

V. Phone/Fax

Practice location:
  • Phone: 317-260-9333
  • Fax:
Mailing address:
  • Phone: 317-260-9333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: JERUSHA KETURAH SEUNG
Title or Position: MEDICAL DIRECTOR AND DIRECTOR OF ED
Credential: APRN, FNP-C, WCC
Phone: 317-260-9333