Provider Demographics
NPI:1558342923
Name:SALZMANN, MARVIN JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:JOHN
Last Name:SALZMANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 COVENTRY LN
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7561
Mailing Address - Country:US
Mailing Address - Phone:815-455-1344
Mailing Address - Fax:815-455-8232
Practice Address - Street 1:460 COVENTRY LN
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7561
Practice Address - Country:US
Practice Address - Phone:815-455-1344
Practice Address - Fax:815-455-8232
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2013-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03641106207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400094399Medicare PIN
C38377Medicare UPIN
ILP01148791Medicare PIN
IL211056005Medicare PIN
254370Medicare ID - Type Unspecified
IL213921005Medicare PIN