MEDICARE: PILSEN PSYCHIATRIC CLINIC & ASSOCIATES, 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	2084P0802X	Addiction Psychiatry Physician
2	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1851645964
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PILSEN PSYCHIATRIC CLINIC & ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	1870 S BLUE ISLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-3013
Country	:	US
Telephone Number	:	312-738-3355
Fax Number	:

Provider Business Practice Location Address
First Line	:	1870 S BLUE ISLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-3013
Country	:	US
Telephone Number	:	312-738-3355
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KRISH VENOO
Credential	:	MD
Telephone Number	:	312-738-3355

Provider Enumeration Date	:	10/29/2012
Last Update Date	:	11/29/2012

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