MEDICARE: ISAAC RAY CENTER AT CERMAK

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	273R00000X	Psychiatric Hospital Unit	071.007792	IL

General Provider Information

NPI Number	:	1669704326
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ISAAC RAY CENTER AT CERMAK

Provider Business Mailing Address
First Line	:	3159 N SEMINARY AVE APT 301
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-3357
Country	:	US
Telephone Number	:	248-765-7127
Fax Number	:

Provider Business Practice Location Address
First Line	:	3159 N SEMINARY #301
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657
Country	:	US
Telephone Number	:	248-765-7127
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOLOGIST
Name	:	DR. KELLY LYNN KUSHNEREIT
Credential	:	PSYD
Telephone Number	:	248-765-7127

Provider Enumeration Date	:	02/05/2010
Last Update Date	:	02/05/2010

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