MEDICARE: MED PSYCHE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1053145888
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MED PSYCHE LLC

Provider Business Mailing Address
First Line	:	1108 W GRANVILLE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-2013
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1108 W GRANVILLE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-2013
Country	:	US
Telephone Number	:	312-912-3444
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BRYAN EVANGELISTA
Credential	:
Telephone Number	:	312-912-3444

Provider Enumeration Date	:	08/26/2024
Last Update Date	:	07/17/2025

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Directions to “MED PSYCHE LLC ” Practice Location

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