Healthcare Provider Details

I. General information

NPI: 1134100688
Provider Name (Legal Business Name): BARRY A ALTSHULER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 12/14/2023
Certification Date: 12/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 E TERRA COTTA AVE SUITE 226
CRYSTAL LAKE IL
60014-3649
US

IV. Provider business mailing address

820 E TERRA COTTA AVE SUITE 226
CRYSTAL LAKE IL
60014-3649
US

V. Phone/Fax

Practice location:
  • Phone: 815-455-2100
  • Fax: 815-455-3284
Mailing address:
  • Phone: 815-455-2100
  • Fax: 815-455-3284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036071366
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier036071366
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: