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NPI Code Detail

MEDICARE: PREMISE HEALTH OF INDIANA MEDICAL, P.C.

MEDICARE: PREMISE HEALTH OF INDIANA MEDICAL, P.C.
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
1207Q00000XFamily Medicine Physician

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1170220OTHERINMEDICARE PTAN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
2CB6836OTHERINGROUP RAILROAD NUMBER

General Provider Information

NPI Number : 1942363841
Entity Type Code : Organization
Provider Name (Legal Business Name) : PREMISE HEALTH OF INDIANA MEDICAL, P.C.
Provider Business Mailing Address
First Line : 5500 MARYLAND WAY STE 120
Second Line :
City : BRENTWOOD
State : TN
Zip : 37027-4993
Country : US
Telephone Number : 216-479-9063
Fax Number :
Provider Business Practice Location Address
First Line : 2022 KELLE DR
Second Line :
City : CHESTERTON
State : IN
Zip : 46304-8708
Country : US
Telephone Number : 219-395-2200
Fax Number : 219-983-1837
Authorized Official
Title or Position : PRESIDENT
Name : JON LEIZMAN
Credential : M.D.
Telephone Number : 216-479-9063
Provider Enumeration Date : 12/19/2006
Last Update Date : 08/25/2022

Similar Medicare Providers

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1932262847 — ANGELA WHEELER M.D.
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46304-8708
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1447305347 — MRS. CATHY ANN KNOX RPH
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1942340435 — NITA MARIE LA FOLLETTE R.PH.
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Directions to “PREMISE HEALTH OF INDIANA MEDICAL, P.C. ” Practice Location

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