Provider Demographics
NPI:1700112224
Name:SOUTH BEND PSYCHIATRY LLC
Entity Type:Organization
Organization Name:SOUTH BEND PSYCHIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:MALLIKARJUN
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-303-5375
Mailing Address - Street 1:11106 BIRCH LAKE DR
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-6032
Mailing Address - Country:US
Mailing Address - Phone:574-303-5375
Mailing Address - Fax:
Practice Address - Street 1:1800 N OAK DR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-3406
Practice Address - Country:US
Practice Address - Phone:574-303-5375
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-19
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty