Basic Information
| Provider Information | |||||||||
| NPI: | 1144467275 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GERIATRIC PSYCHIATRIC SERVICES PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PHD GROUP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28800 RYAN RD | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480924272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5866208100 | ||||||||
| FaxNumber: | 8662277418 | ||||||||
| Practice Location | |||||||||
| Address1: | 28800 RYAN RD | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480924272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5866208100 | ||||||||
| FaxNumber: | 8662277418 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2009 | ||||||||
| LastUpdateDate: | 10/14/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLEMENTE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5866208100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GERIATRIC PSYCHIATRIC SERVICES | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 680F338910 | 01 | MI | BCBS PIN NUMBER | OTHER |