Provider Demographics
NPI:1689896961
Name:SYED MASOOD ALI, MDSC
Entity Type:Organization
Organization Name:SYED MASOOD ALI, MDSC
Other - Org Name:GLEN AVENUE FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAFOLLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-671-8749
Mailing Address - Street 1:4930 N EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4894
Mailing Address - Country:US
Mailing Address - Phone:309-692-7575
Mailing Address - Fax:
Practice Address - Street 1:4930 N EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4894
Practice Address - Country:US
Practice Address - Phone:309-692-7575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067626208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212719OtherMEDICARE GROUP ID
ILE10696Medicare UPIN
IL769552Medicare ID - Type Unspecified