Provider Demographics
NPI:1568620326
Name:CHILD, ADOLESCENT, & ADULT PSYCHIATRY SC
Entity Type:Organization
Organization Name:CHILD, ADOLESCENT, & ADULT PSYCHIATRY SC
Other - Org Name:SLAWOMIR JAN PUSZKARSKI & LUCYNA MARIA PUSZKARSKA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PSYCHIATRIST
Authorized Official - Prefix:MR
Authorized Official - First Name:SLAWOMIR
Authorized Official - Middle Name:JAN
Authorized Official - Last Name:PUSZKARSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-594-9944
Mailing Address - Street 1:5420 N MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630
Mailing Address - Country:US
Mailing Address - Phone:773-594-9944
Mailing Address - Fax:773-594-9944
Practice Address - Street 1:5420 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630
Practice Address - Country:US
Practice Address - Phone:773-594-9944
Practice Address - Fax:773-594-9944
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILD ADOLESCENT & ADULT PSYCHIATRY SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-29
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360916842084P0800X
IL0360937372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-091684Medicaid
IL036-091684Medicaid
ILL64632Medicare PIN