Provider Demographics
NPI:1043206618
Name:SIDDIQUI, ATA U (MD)
Entity Type:Individual
Prefix:
First Name:ATA
Middle Name:U
Last Name:SIDDIQUI
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 1:211 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1915
Mailing Address - Country:US
Mailing Address - Phone:618-234-2120
Mailing Address - Fax:618-641-5810
Practice Address - Street 1:1 SAINT ELIZABETH BLVD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1099
Practice Address - Country:US
Practice Address - Phone:618-234-2120
Practice Address - Fax:618-541-5810
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN4099207L00000X
MO107869207L00000X
IL036-094419207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203941224Medicaid
000090799Medicare PIN
MOG58983Medicare UPIN