Basic Information
| Provider Information | |||||||||
| NPI: | 1356357651 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VALENTE | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 387 SHUMAN BLVD STE 240W | ||||||||
| Address2: | |||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605638113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308682000 | ||||||||
| FaxNumber: | 6308682240 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 S MILWAUKEE AVE | ||||||||
| Address2: | |||||||||
| City: | LIBERTYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600483204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473622900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 12/31/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 36093188 | IL | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 036093188 | IL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 036093188 | 05 | IL | MEDICAID | 1356357651 | 05 | IL | MEDICAID |