Healthcare Provider Details

I. General information

NPI: 1386651461
Provider Name (Legal Business Name): PATRICIA MARIE SALMO PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 10/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4241 HWY 14 WEST REA CLINIC
CHRISTOPHER IL
62822
US

IV. Provider business mailing address

PO BOX 155 REA CLINIC
CHRISTOPHER IL
62822
US

V. Phone/Fax

Practice location:
  • Phone: 618-724-2407
  • Fax: 618-724-2571
Mailing address:
  • Phone: 618-724-2401
  • Fax: 618-724-2571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number085001358
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number085001358
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085001358
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: