Provider Demographics
NPI:1801874565
Name:ALI, MAQBOOL B (MD)
Entity type:Individual
Prefix:
First Name:MAQBOOL
Middle Name:B
Last Name:ALI
Suffix:
Gender:F
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:309-692-7575
Mailing Address - Fax:309-692-0275
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:309-692-0275
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036058850208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212742OtherMEDICARE GROUP NUMBER
ILK23440Medicare PIN
IL212742OtherMEDICARE GROUP NUMBER