Provider Demographics
NPI:1518237585
Name:ALI, MIR M (MD)
Entity Type:Individual
Prefix:
First Name:MIR
Middle Name:M
Last Name:ALI
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 1:1800 HOLLISTER DR STE 112
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5265
Mailing Address - Country:US
Mailing Address - Phone:847-367-6781
Mailing Address - Fax:
Practice Address - Street 1:1800 HOLLISTER DR STE 112
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5265
Practice Address - Country:US
Practice Address - Phone:847-367-6781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-09
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01070723A207R00000X
CA148315207R00000X
NY276959207R00000X
IL036.152740207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201060520Medicaid
INP01105033 RR MCMedicare PIN
INM400070000Medicare PIN