MEDICARE: PSYCHIATRIC INNOVATIONS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1578583910
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSYCHIATRIC INNOVATIONS PC

Provider Business Mailing Address
First Line	:	6920 POINTE INVERNESS WAY
Second Line	:	#250
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-7926
Country	:	US
Telephone Number	:	260-436-4060
Fax Number	:	260-436-5713

Provider Business Practice Location Address
First Line	:	6920 POINTE INVERNESS WAY
Second Line	:	#250
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-7926
Country	:	US
Telephone Number	:	260-436-4060
Fax Number	:	260-436-5713

Authorized Official
Title or Position	:	OWNER
Name	:	JAY D FAWVER
Credential	:	MD
Telephone Number	:	260-436-4060

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	03/30/2012

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