Provider Demographics
NPI:1306172788
Name:GERIATRIC PSYCHIATRIC SERVICES PLLC
Entity type:Organization
Organization Name:GERIATRIC PSYCHIATRIC SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMENTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-519-3650
Mailing Address - Street 1:1721 MOON LAKE BLVD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60169-1069
Mailing Address - Country:US
Mailing Address - Phone:847-519-3650
Mailing Address - Fax:847-519-3652
Practice Address - Street 1:445 S COUNTY ROAD 525 E
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-8361
Practice Address - Country:US
Practice Address - Phone:317-745-2522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ260860OtherMEDICARE PTAN