Provider Demographics
NPI:1336751312
Name:INDYSTATHEALTHEDU, LLC
Entity Type:Organization
Organization Name:INDYSTATHEALTHEDU, LLC
Other - Org Name:INDYSTATHEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR AND DIRECTOR OF ED
Authorized Official - Prefix:
Authorized Official - First Name:JERUSHA
Authorized Official - Middle Name:KETURAH
Authorized Official - Last Name:SEUNG
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, FNP-C, WCC
Authorized Official - Phone:317-260-9333
Mailing Address - Street 1:9465 COUNSELORS ROW STE 200
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-3817
Mailing Address - Country:US
Mailing Address - Phone:317-260-9333
Mailing Address - Fax:
Practice Address - Street 1:9465 COUNSELORS ROW STE 200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-3817
Practice Address - Country:US
Practice Address - Phone:317-260-9333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INDYSTATHEALTHEDU, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-08-20
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Single Specialty