MEDICARE: DR. MARIO A. SALAZAR M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	036-049655	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	21605529	OTHER	IL	BLUE CROSS/BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	363129476	OTHER	IL	TAX ID

General Provider Information

NPI Number	:	1003915620
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIO A. SALAZAR M.D.

Provider Business Mailing Address
First Line	:	3048 N HARLEM AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-4704
Country	:	US
Telephone Number	:	773-237-7795
Fax Number	:	773-237-7547

Provider Business Practice Location Address
First Line	:	3048 N HARLEM AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-4704
Country	:	US
Telephone Number	:	773-237-7795
Fax Number	:	773-237-7547

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	07/08/2007

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