Provider Demographics
NPI:1336440122
Name:PROFESSIONAL DEVELOPMENT ASSOCIATES, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL DEVELOPMENT ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:WERNERT
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:1317-445-5016
Mailing Address - Street 1:1776 SUMMERLAKES CT
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-9679
Mailing Address - Country:US
Mailing Address - Phone:888-822-9732
Mailing Address - Fax:888-822-9732
Practice Address - Street 1:1776 SUMMERLAKES CT
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-9679
Practice Address - Country:US
Practice Address - Phone:888-822-9732
Practice Address - Fax:888-822-9732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-09
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035237A2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100134210AMedicaid
1851364780OtherPERSONAL NPI - DR. WERNERT
IN100134210AMedicaid
IND46997Medicare UPIN