Provider Demographics
NPI:1922210178
Name:SIDDIQUI, ALI H (MD)
Entity Type:Individual
Prefix:
First Name:ALI
Middle Name:H
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 1:4805 S MOORLAND RD
Mailing Address - Street 2:MOORLAND RESERVE
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-7401
Mailing Address - Country:US
Mailing Address - Phone:262-798-7200
Mailing Address - Fax:262-798-7201
Practice Address - Street 1:4805 S MOORLAND RD
Practice Address - Street 2:MOORLAND RESERVE
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-7401
Practice Address - Country:US
Practice Address - Phone:262-798-7200
Practice Address - Fax:262-798-7201
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL336082767207Q00000X
WI65022207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0361214262Medicaid
ILP00968583OtherRRMCARE THRU CES
IL210426012Medicare PIN
IL0361214262Medicaid