Provider Demographics
NPI:1306090691
Name:WIS-PER PSYCHIATRIC SERVICES S.C.
Entity type:Organization
Organization Name:WIS-PER PSYCHIATRIC SERVICES S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RITA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:LEWIS-PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-296-1759
Mailing Address - Street 1:16233 WAUSAU AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-2157
Mailing Address - Country:US
Mailing Address - Phone:708-643-1753
Mailing Address - Fax:708-418-0620
Practice Address - Street 1:16233 WAUSAU AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-2157
Practice Address - Country:US
Practice Address - Phone:708-643-1753
Practice Address - Fax:708-418-0620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-12
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0849742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036084974Medicaid
ILF41320Medicare UPIN