Provider Demographics
NPI:1104063239
Name:GERIATRIC PSYCHIATRIC SERVICES PLLC
Entity type:Organization
Organization Name:GERIATRIC PSYCHIATRIC SERVICES PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLEMENTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-620-8100
Mailing Address - Street 1:39465 W 14 MILE RD
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-1600
Mailing Address - Country:US
Mailing Address - Phone:248-859-3900
Mailing Address - Fax:888-483-0118
Practice Address - Street 1:28800 RYAN RD
Practice Address - Street 2:SUITE 320
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-4272
Practice Address - Country:US
Practice Address - Phone:586-620-8100
Practice Address - Fax:866-227-7418
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GERIATRIC PSYCHIATRIC SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-12
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult HealthGroup - Single Specialty
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, AdultGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI500F339520OtherBCBS PIN NUMBER
0P39330Medicare PIN