Provider Demographics
NPI:1659441905
Name:ANDERSON PSYCHIATRIC CLINIC LLC
Entity Type:Organization
Organization Name:ANDERSON PSYCHIATRIC CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:WENGER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:765-649-2234
Mailing Address - Street 1:431 WEST 9TH STREET
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46016-1317
Mailing Address - Country:US
Mailing Address - Phone:765-649-2234
Mailing Address - Fax:765-640-0538
Practice Address - Street 1:431 WEST 9TH STREET
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-1317
Practice Address - Country:US
Practice Address - Phone:765-649-2234
Practice Address - Fax:765-640-0538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100170630AMedicaid
IN133450Medicare PIN
IN133400Medicare PIN
IN133410Medicare PIN