Provider Demographics
NPI:1003949793
Name:MIDWEST NEUROPSYCHIATRIC ASSOC LTD
Entity Type:Organization
Organization Name:MIDWEST NEUROPSYCHIATRIC ASSOC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLEY
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:312-942-9319
Mailing Address - Street 1:1725 W HARRISON ST
Mailing Address - Street 2:SUITE 744
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3841
Mailing Address - Country:US
Mailing Address - Phone:312-942-0118
Mailing Address - Fax:312-942-1331
Practice Address - Street 1:1725 W HARRISON ST
Practice Address - Street 2:SUITE 744
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3841
Practice Address - Country:US
Practice Address - Phone:312-942-0118
Practice Address - Fax:312-942-1331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042002366174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1615745OtherBLUE CROSS-BLUE SHIELD #