1063818771 NPI number — PREMISE HEALTH OF INDIANA MEDICAL, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063818771 NPI number — PREMISE HEALTH OF INDIANA MEDICAL, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMISE HEALTH OF INDIANA MEDICAL, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ROCHE WELLNESS CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063818771
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/25/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5500 MARYLAND WAY STE 120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-4993
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9115 HAGUE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46256-1025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-521-3600
Provider Business Practice Location Address Fax Number:
317-521-4435
Provider Enumeration Date:
11/06/2014

Additional Information

Authorized Official

Authorized Official Last Name:
LEIZMAN
Authorized Official First Name:
JON
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
216-479-9063

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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