1730328832 NPI number — GERIATRIC PSYCHIATRIC SERVICES PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730328832 NPI number — GERIATRIC PSYCHIATRIC SERVICES PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GERIATRIC PSYCHIATRIC SERVICES PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730328832
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28800 RYAN RD
Provider Second Line Business Mailing Address:
SUITE 320
Provider Business Mailing Address City Name:
WARREN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48092-4272
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-620-8100
Provider Business Mailing Address Fax Number:
866-227-7418

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 WESTBROOK CORPORATE CTR
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
WESTCHESTER
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60154-5701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-375-3075
Provider Business Practice Location Address Fax Number:
866-227-7418
Provider Enumeration Date:
02/12/2009

Additional Information

Authorized Official

Authorized Official Last Name:
CLEMENTE
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
A
Authorized Official Title or Position:
ADMIN DIR.
Authorized Official Telephone Number:
586-620-8100

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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