Provider Demographics
NPI:1942972047
Name:INDIANA PSYCHIATRIC ASSOCIATES LLC
Entity Type:Organization
Organization Name:INDIANA PSYCHIATRIC ASSOCIATES LLC
Other - Org Name:QPM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:SATYA
Authorized Official - Middle Name:KISHORE
Authorized Official - Last Name:GUTTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-208-9676
Mailing Address - Street 1:4656 W JEFFERSON BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6857
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4656 W JEFFERSON BLVD STE 201
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6857
Practice Address - Country:US
Practice Address - Phone:978-000-0001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-28
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty