Provider Demographics
NPI:1427345131
Name:SELECT PSYCHIATRIC MANAGEMENT GROUP LLC
Entity type:Organization
Organization Name:SELECT PSYCHIATRIC MANAGEMENT GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:NAEEM
Authorized Official - Middle Name:AKHTAR
Authorized Official - Last Name:QURESHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-998-0888
Mailing Address - Street 1:112 AIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5841
Mailing Address - Country:US
Mailing Address - Phone:618-998-0888
Mailing Address - Fax:618-993-1808
Practice Address - Street 1:100 DR WARREN TUTTLE DR
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-2718
Practice Address - Country:US
Practice Address - Phone:618-252-0999
Practice Address - Fax:618-252-2032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-01
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036094666Medicaid