MEDICARE: RAUL SALTA

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	036048835	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	791133428	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	3160049878	OTHER	IL	BCBS IL
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588760524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAUL SALTA

Provider Business Mailing Address
First Line	:	5219 N HARLEM AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60656-1803
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1705 W GRANVILLE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-1114
Country	:	US
Telephone Number	:	773-262-8760
Fax Number	:

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

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	09/08/2009

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Directions to “ RAUL SALTA ” Practice Location

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