Provider Demographics
NPI:1346305067
Name:AUGUSTO MONTALVO, MDSC
Entity Type:Organization
Organization Name:AUGUSTO MONTALVO, MDSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AUGUSTO
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTALVO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-729-5000
Mailing Address - Street 1:2400 RAVINE WAY
Mailing Address - Street 2:SUITE#400
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-7652
Mailing Address - Country:US
Mailing Address - Phone:847-729-5000
Mailing Address - Fax:847-729-9506
Practice Address - Street 1:2400 RAVINE WAY
Practice Address - Street 2:SUITE#400
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-7652
Practice Address - Country:US
Practice Address - Phone:847-729-5000
Practice Address - Fax:847-729-9506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL336044595207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01632585OtherBLUE CROSS BLUE SHIELD
IL204328Medicare ID - Type Unspecified
ILF85692Medicare UPIN