Healthcare Provider Details

I. General information

NPI: 1679662514
Provider Name (Legal Business Name): MILES TODD SALSMAN C.R.N.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 12/31/2020
Certification Date: 12/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 PARK AVE EAST
PRINCETON IL
61356
US

IV. Provider business mailing address

1011 PHEASANT RIDGE LN
PRINCETON IL
61356-8616
US

V. Phone/Fax

Practice location:
  • Phone: 815-875-2811
  • Fax:
Mailing address:
  • Phone: 815-872-1060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209-004503
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: