Healthcare Provider Details

I. General information

NPI: 1295834901
Provider Name (Legal Business Name): SALLY J SALMONS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 05/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E. SOUTHLINE ROAD
TUSCOLA IL
61953
US

IV. Provider business mailing address

611 W. PARK ST. BWPC
URBANA IL
61801-2500
US

V. Phone/Fax

Practice location:
  • Phone: 217-253-5231
  • Fax: 217-253-4082
Mailing address:
  • Phone: 217-383-6792
  • Fax: 217-383-4752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036108100
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: