Provider Demographics
NPI:1316031081
Name:PREMISE HEALTH OF INDIANA MEDICAL, P.C.
Entity Type:Organization
Organization Name:PREMISE HEALTH OF INDIANA MEDICAL, P.C.
Other - Org Name:USS FAMILY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:LEIZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-479-9063
Mailing Address - Street 1:5500 MARYLAND WAY
Mailing Address - Street 2:ATTN: CBO
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4948
Mailing Address - Country:US
Mailing Address - Phone:800-830-4255
Mailing Address - Fax:615-296-0151
Practice Address - Street 1:251 W 84TH DR
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6243
Practice Address - Country:US
Practice Address - Phone:219-756-4343
Practice Address - Fax:219-756-4382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INDF9175OtherMEDICARE RAIL ROAD
IN405160Medicare PIN