Healthcare Provider Details

I. General information

NPI: 1619951860
Provider Name (Legal Business Name): NEUROPSYCHIATRIC EVALUATION AND TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 09/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3633 W LAKE AVE SUITE 404
GLENVIEW IL
60026-5805
US

IV. Provider business mailing address

3633 W LAKE AVE SUITE 404
GLENVIEW IL
60026-5805
US

V. Phone/Fax

Practice location:
  • Phone: 847-657-6007
  • Fax: 847-657-6412
Mailing address:
  • Phone: 847-657-6007
  • Fax: 847-657-6412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036-069110
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number036-069110
License Number StateIL

VIII. Authorized Official

Name: DR. ROBERT W BLOOM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 847-657-6007