Healthcare Provider Details

I. General information

NPI: 1851645964
Provider Name (Legal Business Name): PILSEN PSYCHIATRIC CLINIC & ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2012
Last Update Date: 11/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1870 S BLUE ISLAND AVE
CHICAGO IL
60608-3013
US

IV. Provider business mailing address

1870 S BLUE ISLAND AVE
CHICAGO IL
60608-3013
US

V. Phone/Fax

Practice location:
  • Phone: 312-738-3355
  • Fax:
Mailing address:
  • Phone: 312-738-3355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KRISH VENOO
Title or Position: OWNER
Credential: MD
Phone: 312-738-3355