Provider Demographics
NPI:1801019096
Name:PANCNER PSYCHIATRIC ASSOCIATES, PC
Entity Type:Organization
Organization Name:PANCNER PSYCHIATRIC ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:PANCNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-456-4880
Mailing Address - Street 1:2805 FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46807-1218
Mailing Address - Country:US
Mailing Address - Phone:260-456-4880
Mailing Address - Fax:260-456-3559
Practice Address - Street 1:2805 FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46807-1218
Practice Address - Country:US
Practice Address - Phone:260-456-4880
Practice Address - Fax:260-456-3559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100049440Medicaid
IN137100Medicare PIN
IN100049440Medicaid