1427148782 NPI number — FORT WAYNE PSYCHIATRY. P. C.

Table of content: (NPI 1427148782)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427148782 NPI number — FORT WAYNE PSYCHIATRY. P. C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FORT WAYNE PSYCHIATRY. P. C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427148782
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3400 E COLISEUM BLVD
Provider Second Line Business Mailing Address:
STE 340
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46805-1644
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-484-1312
Provider Business Mailing Address Fax Number:
260-471-0996

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3400 E COLISEUM BLVD
Provider Second Line Business Practice Location Address:
STE 340
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46805-1644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-484-1312
Provider Business Practice Location Address Fax Number:
260-471-0996
Provider Enumeration Date:
10/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RUSTAGI
Authorized Official First Name:
PREVESH
Authorized Official Middle Name:
KUMAR
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
260-484-1312

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100389780A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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