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General NPI Number Information
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NPI Number | 1427148782
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Entity Type | Organization
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Legal Business Name | FORT WAYNE PSYCHIATRY. P. C.
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Dates
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Enumeration Date | 10/14/2006
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Last Update Date | 01/15/2017
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Provider Practice Location Address
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Address Line | 3400 E COLISEUM BLVD STE 340
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City | FORT WAYNE
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State | IN
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Zip | 46805-1644
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Country | US
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Telephone | 260-484-1312
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Fax | 260-471-0996
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Provider Business Mailing Address
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Address Line | 3400 E COLISEUM BLVD STE 340
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City | FORT WAYNE
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State | IN
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Zip | 46805-1644
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Country | US
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Telephone | 260-484-1312
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Fax | 260-471-0996
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. PREVESH KUMAR RUSTAGI
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Credential | M. D.
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Telephone | 260-484-1312
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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