Basic Information
| Provider Information | |||||||||
| NPI: | 1942363841 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMISE HEALTH OF INDIANA MEDICAL, P.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | STEEL FAMILY HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5500 MARYLAND WAY STE 120 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370274993 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164799063 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2022 KELLE DR | ||||||||
| Address2: | |||||||||
| City: | CHESTERTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463048708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193952200 | ||||||||
| FaxNumber: | 2199831837 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 08/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | LEIZMAN | ||||||||
| AuthorizedOfficialFirstName: | JON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2164799063 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 08/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 170220 | 01 | IN | MEDICARE PTAN | OTHER | CB6836 | 01 | IN | GROUP RAILROAD NUMBER | OTHER |