Provider Demographics
NPI:1427148782
Name:FORT WAYNE PSYCHIATRY. P. C.
Entity type:Organization
Organization Name:FORT WAYNE PSYCHIATRY. P. C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PREVESH
Authorized Official - Middle Name:KUMAR
Authorized Official - Last Name:RUSTAGI
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:260-484-1312
Mailing Address - Street 1:3400 E COLISEUM BLVD
Mailing Address - Street 2:STE 340
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-1644
Mailing Address - Country:US
Mailing Address - Phone:260-484-1312
Mailing Address - Fax:260-471-0996
Practice Address - Street 1:3400 E COLISEUM BLVD
Practice Address - Street 2:STE 340
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1644
Practice Address - Country:US
Practice Address - Phone:260-484-1312
Practice Address - Fax:260-471-0996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-14
Last Update Date:2017-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100389780AMedicaid
218700Medicare PIN