Provider Demographics
NPI:1073753323
Name:GERIATRIC PSYCHIATRIC SERVICES PLLC
Entity Type:Organization
Organization Name:GERIATRIC PSYCHIATRIC SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLEMENTE
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:586-620-8100
Mailing Address - Street 1:28800 RYAN RD
Mailing Address - Street 2:SUITE 320
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-4272
Mailing Address - Country:US
Mailing Address - Phone:586-620-8100
Mailing Address - Fax:866-227-7418
Practice Address - Street 1:9465 COUNSELORS ROW
Practice Address - Street 2:SUITE 200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-6423
Practice Address - Country:US
Practice Address - Phone:586-620-8100
Practice Address - Fax:866-227-7418
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TOTAL CARE SOLUTIONS, SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-26
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN260860Medicare PIN