Provider Demographics
NPI:1528413747
Name:PILSEN PSYCHIATRIC CLINIC & ASSOCIATES LLC
Entity Type:Organization
Organization Name:PILSEN PSYCHIATRIC CLINIC & ASSOCIATES LLC
Other - Org Name:HOPE COMMUNITY AND FAMILY CENTER OF CHICAGO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISH
Authorized Official - Middle Name:
Authorized Official - Last Name:VENOO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-564-5246
Mailing Address - Street 1:3350 S KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-5114
Mailing Address - Country:US
Mailing Address - Phone:312-564-5246
Mailing Address - Fax:312-564-5253
Practice Address - Street 1:3350 S KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-5114
Practice Address - Country:US
Practice Address - Phone:312-564-5246
Practice Address - Fax:312-564-5253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-25
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL16001251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL248000794Medicaid