Provider Demographics
NPI:1679662514
Name:SALSMAN, MILES TODD (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MILES
Middle Name:TODD
Last Name:SALSMAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 PHEASANT RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356-8616
Mailing Address - Country:US
Mailing Address - Phone:815-872-1060
Mailing Address - Fax:
Practice Address - Street 1:530 PARK AVE EAST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356
Practice Address - Country:US
Practice Address - Phone:815-875-2811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-004503367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP77501Medicare UPIN