Provider Demographics
NPI:1467492173
Name:GERIATRIC PSYCHIATRIC SERVICES PLLC
Entity type:Organization
Organization Name:GERIATRIC PSYCHIATRIC SERVICES PLLC
Other - Org Name:
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 1:1715 INDIAN WOOD CIR STE 200
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-4055
Practice Address - Country:US
Practice Address - Phone:877-906-9699
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI260F340040OtherBCBS PHYSICIAN GROUP
MI0P39330Medicare PIN