Provider Demographics
NPI:1194913228
Name:PSYCHIATRIC SERVICES P C
Entity type:Organization
Organization Name:PSYCHIATRIC SERVICES P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:MAHENDER
Authorized Official - Middle Name:REDDY
Authorized Official - Last Name:SURAKANTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-425-3204
Mailing Address - Street 1:PO BOX 40139
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-0139
Mailing Address - Country:US
Mailing Address - Phone:260-425-3204
Mailing Address - Fax:260-425-3206
Practice Address - Street 1:800 BROADWAY
Practice Address - Street 2:STE 208
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-2149
Practice Address - Country:US
Practice Address - Phone:260-425-3204
Practice Address - Fax:260-425-3206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057700A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN207300AMedicare PIN