Healthcare Provider Details

I. General information

NPI: 1053435222
Provider Name (Legal Business Name): SALVATORE ANTONIO FANTO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 04/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11304 W DISTINCTIVE DRIVE
ORLAND PARK IL
60462
US

IV. Provider business mailing address

PO BOX 2087
ORLAND PARK IL
60462
US

V. Phone/Fax

Practice location:
  • Phone: 708-479-0005
  • Fax: 708-479-0022
Mailing address:
  • Phone: 708-364-0075
  • Fax: 708-364-1115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number036076529
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: