Provider Demographics
NPI:1417902065
Name:PROFESSIONAL PSYCHIATRIC SERVICES P.C.
Entity Type:Organization
Organization Name:PROFESSIONAL PSYCHIATRIC SERVICES P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:ANGELO
Authorized Official - Last Name:RACANIELLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-947-2097
Mailing Address - Street 1:6722 ERIE RD
Mailing Address - Street 2:PO BOX 803
Mailing Address - City:DERBY
Mailing Address - State:NY
Mailing Address - Zip Code:14047-9670
Mailing Address - Country:US
Mailing Address - Phone:716-947-2097
Mailing Address - Fax:716-947-5909
Practice Address - Street 1:6722 ERIE RD
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:NY
Practice Address - Zip Code:14047-9670
Practice Address - Country:US
Practice Address - Phone:716-947-2097
Practice Address - Fax:716-947-5909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1885852084P0800X, 2084P0802X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty