Healthcare Provider Details

I. General information

NPI: 1134874589
Provider Name (Legal Business Name): JOHNATHAN SALVI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2022
Last Update Date: 02/15/2022
Certification Date: 02/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 N MAIN ST
ALGONQUIN IL
60102-3482
US

IV. Provider business mailing address

1106 N MAIN ST
ALGONQUIN IL
60102-3482
US

V. Phone/Fax

Practice location:
  • Phone: 224-333-0928
  • Fax: 224-209-8685
Mailing address:
  • Phone: 224-333-0928
  • Fax: 224-209-8685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-008870
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: