NPIMap

Organization Active NPI

Premise Health of Indiana Medical PC

Doing business as BAE Systems Fort Wayne IN

  • Occupational Medicine Clinic/Center
  • Fort Wayne, IN
National Provider Identifier
1033700158
Registry record updated Oct 29, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Occupational Medicine Clinic/CenterTaxonomy code 261QX0100X
Legal business name
PREMISE HEALTH OF INDIANA MEDICAL PC
Doing business as
BAE Systems Fort Wayne IN
Practice address
4250 Airport Expy
Fort Wayne, IN 46809-9643
Phone
(260) 434-5053
Fax
(260) 434-5413
NPI assigned
Feb 1, 2021
Last updated
Oct 29, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 29, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Jon Leizman, MD
Title
President
Phone
(615) 468-6270

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Occupational Medicine Clinic/Center 261QX0100X NU Primary

Addresses

Primary practice location

4250 Airport Expy
Fort Wayne, IN 46809-9643

Mailing address

5500 Maryland Way Ste 120
Brentwood, TN 37027-4993

Other names 1

  • BAE Systems Fort Wayne IN Doing business as

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
15D2080384Premise Health of Indiana Medical, PC4250 Airport Expressway, Fwi, Fort Wayne, IN 46809Certificate of waiverJul 6, 2028

National Provider Directory

National Provider Directory
Tax ID family
Premise Health of Indiana Medical PC26 organizations share this tax ID, including this one

Other organizations with this tax ID 25

Organizations that report the same tax identification number in the National Provider Directory.

View all 25

Locations

4250 Airport Expy
Fort Wayne, IN 46809
Phone (260) 434-5053

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1612137600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1730160000000",
    "number": "1033700158",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5500 MARYLAND WAY STE 120",
            "city": "BRENTWOOD",
            "state": "TN",
            "postal_code": "370274993"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4250 AIRPORT EXPY",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468099643",
            "telephone_number": "260-434-5053",
            "fax_number": "260-434-5413"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PREMISE HEALTH OF INDIANA MEDICAL PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-02-01",
        "last_updated": "2024-10-29",
        "certification_date": "2024-10-29",
        "status": "A",
        "authorized_official_last_name": "LEIZMAN",
        "authorized_official_first_name": "JON",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "615-468-6270",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QX0100X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Occupational Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "BAE Systems Fort Wayne IN",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "BAE Systems Fort Wayne IN",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fort Wayne, IN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 29, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.