1033301189 NPI number — PSYCHIATRIC SERVICES PC

Table of content: (NPI 1033301189)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033301189 NPI number — PSYCHIATRIC SERVICES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PSYCHIATRIC SERVICES PC
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:
6
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:
1033301189
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
701 MISTY CREEK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW LENOX
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60451
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-485-2163
Provider Business Mailing Address Fax Number:
815-485-6567

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 BATSON ST
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
NEW LENOX
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60451
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-485-2885
Provider Business Practice Location Address Fax Number:
815-485-2185
Provider Enumeration Date:
08/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LELIO
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
FRANCIS
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
815-485-2163

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0850X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 533810 . This is a "MEDICARE ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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