Healthcare Provider Details

I. General information

NPI: 1386875276
Provider Name (Legal Business Name): SALVATORE ANTHONY DEPASQUALE SA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: SAM DEPASQUALE SA-C

II. Dates (important events)

Enumeration Date: 07/27/2009
Last Update Date: 04/25/2023
Certification Date: 04/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8238 KNICKERBOCKER PL
SAINT JOHN IN
46373-9438
US

IV. Provider business mailing address

8238 KNICKERBOCKER PL
SAINT JOHN IN
46373-9438
US

V. Phone/Fax

Practice location:
  • Phone: 708-990-8737
  • Fax: 708-564-5062
Mailing address:
  • Phone: 708-990-8737
  • Fax: 708-564-5062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number238.000224
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: