Provider Demographics
NPI:1407166077
Name:PROFESSIONAL PSYCHIATRIC SERVICES, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL PSYCHIATRIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:S.
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:SHIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-615-1216
Mailing Address - Street 1:11012 W SYCAMORE HILLS DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-9308
Mailing Address - Country:US
Mailing Address - Phone:260-969-9696
Mailing Address - Fax:260-969-7979
Practice Address - Street 1:6203 CONSTITUTION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1517
Practice Address - Country:US
Practice Address - Phone:260-969-9696
Practice Address - Fax:260-969-7979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-18
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty