Provider Demographics
NPI:1700805439
Name:ALI, SYED MASOOD (MD)
Entity Type:Individual
Prefix:DR
First Name:SYED
Middle Name:MASOOD
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 1:4930 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:309-691-3707
Mailing Address - Fax:309-692-0270
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:309-691-3707
Practice Address - Fax:309-692-0270
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03-6037626207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212719OtherMEDICARE GROUP NUMBER
IL212719OtherMEDICARE GROUP NUMBER
ILE-10696Medicare UPIN