Basic Information
Provider Information | |||||||||
NPI: | 1891935144 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GERIATRIC PSYCHIATRIC SERVICES PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 28800 RYAN RD | ||||||||
Address2: | SUITE 320 | ||||||||
City: | WARREN | ||||||||
State: | MI | ||||||||
PostalCode: | 480924272 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5866208100 | ||||||||
FaxNumber: | 8662277418 | ||||||||
Practice Location | |||||||||
Address1: | 9465 COUNSELORS ROW | ||||||||
Address2: | SUITE 200 | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462406423 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5866208100 | ||||||||
FaxNumber: | 8662277418 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/26/2009 | ||||||||
LastUpdateDate: | 01/15/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CLEMENTE | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | ADMIN DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5866208100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | TOTAL CARE SOLUTIONS, SC | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | ESQ. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.