Provider Demographics
NPI:1366748097
Name:SUSANA SALCEDO MD LLC
Entity type:Organization
Organization Name:SUSANA SALCEDO MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSANA
Authorized Official - Middle Name:
Authorized Official - Last Name:SALCEDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-299-7784
Mailing Address - Street 1:1600 W DEMPSTER ST STE 120
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1171
Mailing Address - Country:US
Mailing Address - Phone:847-299-7784
Mailing Address - Fax:
Practice Address - Street 1:1600 W DEMPSTER ST STE 120
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1171
Practice Address - Country:US
Practice Address - Phone:847-299-7784
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-27
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036120503207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036120503Medicaid