Provider Demographics
NPI:1083841076
Name:AERIES HEALTHCARE OF ILLINOIS PHYSICIAN GROUP
Entity type:Organization
Organization Name:AERIES HEALTHCARE OF ILLINOIS PHYSICIAN GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-209-4156
Mailing Address - Street 1:PO BOX 840936
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:72584
Mailing Address - Country:US
Mailing Address - Phone:708-209-4152
Mailing Address - Fax:
Practice Address - Street 1:8311 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130
Practice Address - Country:US
Practice Address - Phone:708-209-4150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVEREDEGE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-17
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
144009Medicare UPIN