Provider Demographics
NPI:1245302934
Name:FAMILY PSYCHIATRIC CENTER LLC
Entity type:Organization
Organization Name:FAMILY PSYCHIATRIC CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:M.D. DBA
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROEGNER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:765-453-7422
Mailing Address - Street 1:PO BOX 6459
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46904-6459
Mailing Address - Country:US
Mailing Address - Phone:765-453-7422
Mailing Address - Fax:765-453-3773
Practice Address - Street 1:702 W ALTO RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-4907
Practice Address - Country:US
Practice Address - Phone:765-453-7422
Practice Address - Fax:765-453-3773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN101YM0800X, 1041C0700X
IN20010245103TC0700X
IN28095903A363LP0808X
IN010234092084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100154150AMedicaid
IN100154150AMedicaid
IN225230Medicare PIN