Premier Pediatrics of Indiana LLC

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

Legal business name

PREMIER PEDIATRICS OF INDIANA LLC

Practice address

229 Florence Ave Ste 233
Granger, IN 46530-8048

Phone

(574) 855-4575

NPI assigned

Nov 11, 2020

Last updated

Jul 20, 2021By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Charisse Johnson, MDNPI 1134399025

Title

Sole Proprietor

Phone

(317) 345-3142

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in IN

Enrollment records 1

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

CLIA laboratory certificates

Locations

Interoperability endpoints

• FHIR API: https://api.platform.athenahealth.com/22638/brand/1/csg/1/fhir/r4

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Charisse D Johnson, MD

  • Pediatrics Physician
  • Granger, IN
  • NPI 1134399025
  Medicare reassignment NPD Authorized official

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

{
    "created_epoch": "1605052800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1626739200000",
    "number": "1760084156",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "229 FLORENCE AVE STE 233",
            "city": "GRANGER",
            "state": "IN",
            "postal_code": "465308048",
            "telephone_number": "574-855-4575"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "229 FLORENCE AVE STE 233",
            "city": "GRANGER",
            "state": "IN",
            "postal_code": "465308048",
            "telephone_number": "574-855-4575"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PREMIER PEDIATRICS OF INDIANA LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-11-11",
        "last_updated": "2021-07-20",
        "certification_date": "2021-07-20",
        "status": "A",
        "authorized_official_last_name": "JOHNSON",
        "authorized_official_first_name": "CHARISSE",
        "authorized_official_title_or_position": "SOLE PROPRIETOR",
        "authorized_official_telephone_number": "317-345-3142",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Tara Polk
• Amanda Lynn Ponce de Leon, DPT
• Amy Marie Pope, P.A.-C
• Sara Porter, DVM
• Powerback Rehabilitation LLC
• Prudent Homecare LLC
• Nancy Anne Pudlo, MD
• Karen Ann Pugh, O.D.
• Sharon Lee Quaco, OT
• Quality Care Pediatrics

• Pediatrics Physician in Granger, IN
• Providers in Granger, IN by specialty
• Pediatrics Physician in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 20, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• 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.