Provider Demographics
NPI:1922199967
Name:AL-BASHA, MARIA I (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:I
Last Name:AL-BASHA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:ROEHRS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 775541
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-5541
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1639 N ALPINE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-1449
Practice Address - Country:US
Practice Address - Phone:815-229-9333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036079495207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036079495Medicaid
IL911671Medicare PIN
ILE30915Medicare UPIN