Provider Demographics
NPI:1275652778
Name:SALLIN, SCOTT M (PT)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:M
Last Name:SALLIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10100 FOREST HILLS RD
Mailing Address - Street 2:PHYSICIANS IMMEDIATE CARE
Mailing Address - City:MACHESNEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61115-8234
Mailing Address - Country:US
Mailing Address - Phone:815-713-2600
Mailing Address - Fax:815-654-8020
Practice Address - Street 1:391 S BOLINGBROOK DR
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-3411
Practice Address - Country:US
Practice Address - Phone:630-243-4820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070010195225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213992Medicare PIN
IL204591Medicare PIN
ILR00030Medicare PIN