Provider Demographics
NPI:1659531549
Name:CLINIC OF PSYCHIATRIC CARE
Entity Type:Organization
Organization Name:CLINIC OF PSYCHIATRIC CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-965-8505
Mailing Address - Street 1:1752 WINDSOR RD
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-4280
Mailing Address - Country:US
Mailing Address - Phone:815-986-2620
Mailing Address - Fax:
Practice Address - Street 1:1752 WINDSOR RD
Practice Address - Street 2:STE 203
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-4280
Practice Address - Country:US
Practice Address - Phone:815-986-2620
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-13
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360768242084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10127233OtherBCBS ID