Provider Demographics
NPI:1639381817
Name:QURESHI, MARYAM (MD)
Entity Type:Individual
Prefix:DR
First Name:MARYAM
Middle Name:
Last Name:QURESHI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2300 N EDWARD ST
Mailing Address - Street 2:GSBLL
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4163
Mailing Address - Country:US
Mailing Address - Phone:217-876-2857
Mailing Address - Fax:217-876-2874
Practice Address - Street 1:241 W WEAVER RD
Practice Address - Street 2:SUITE 145D
Practice Address - City:FORSYTH
Practice Address - State:IL
Practice Address - Zip Code:62535-9762
Practice Address - Country:US
Practice Address - Phone:217-876-5250
Practice Address - Fax:217-876-5255
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL125-051850207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036123157Medicaid