Basic Information
| Provider Information | |||||||||
| NPI: | 1306172788 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GERIATRIC PSYCHIATRIC SERVICES PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1721 MOON LAKE BLVD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | HOFFMAN ESTATES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601691069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475193650 | ||||||||
| FaxNumber: | 8475193652 | ||||||||
| Practice Location | |||||||||
| Address1: | 445 S COUNTY ROAD 525 E | ||||||||
| Address2: | |||||||||
| City: | AVON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461238361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177452522 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2009 | ||||||||
| LastUpdateDate: | 10/20/2009 | ||||||||
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| AuthorizedOfficialLastName: | CLEMENTE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8475193650 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | IN260860 | 01 | IN | MEDICARE PTAN | OTHER |