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General NPI Number Information
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NPI Number | 1194913228
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Entity Type | Organization
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Legal Business Name | PSYCHIATRIC SERVICES P C
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Dates
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Enumeration Date | 10/15/2007
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Last Update Date | 02/05/2010
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Provider Practice Location Address
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Address Line | 800 BROADWAY STE 208
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City | FORT WAYNE
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State | IN
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Zip | 46802-2149
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Country | US
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Telephone | 260-425-3204
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Fax | 260-425-3206
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Provider Business Mailing Address
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Address Line | PO BOX 40139
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City | FORT WAYNE
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State | IN
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Zip | 46804-0139
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Country | US
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Telephone | 260-425-3204
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Fax | 260-425-3206
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Authorized Official
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Title or Position | M.D.
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Name | DR. MAHENDER REDDY SURAKANTI
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Credential | M.D
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Telephone | 260-425-3204
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 01057700A
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License Number State | IN
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