MEDICARE: INDIANA ADVANCED PSYCHIATRY

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	:	1861253742
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDIANA ADVANCED PSYCHIATRY

Provider Business Mailing Address
First Line	:	1700 W BIG BEAVER RD STE 300
Second Line	:
City	:	TROY
State	:	MI
Zip	:	48084-3514
Country	:	US
Telephone Number	:	260-888-1378
Fax Number	:	260-387-6763

Provider Business Practice Location Address
First Line	:	7230 ENGLE RD STE 102
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-2234
Country	:	US
Telephone Number	:	260-888-1378
Fax Number	:	260-387-6763

Authorized Official
Title or Position	:	RCM DIRECTOR
Name	:	DONNELLE BACON
Credential	:
Telephone Number	:	810-357-6984

Provider Enumeration Date	:	01/18/2024
Last Update Date	:	02/09/2026

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