Provider Demographics
NPI:1659795466
Name:PROFESSIONAL PSYCHIATRIC ASSOCIATES INC
Entity Type:Organization
Organization Name:PROFESSIONAL PSYCHIATRIC ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IFTIKHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:RASUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-206-0015
Mailing Address - Street 1:2545 PARTRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33884-3033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2545 PARTRIDGE DR
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33884-3033
Practice Address - Country:US
Practice Address - Phone:863-206-0015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-13
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME886132084P0800X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL43193ZMedicaid