Provider Demographics
NPI:1912444209
Name:ALI, HUSAM M (MD)
Entity Type:Individual
Prefix:
First Name:HUSAM
Middle Name:M
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 1:7821 W 144TH ST
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-2962
Mailing Address - Country:US
Mailing Address - Phone:708-262-4876
Mailing Address - Fax:708-636-0905
Practice Address - Street 1:9848 SOUTHWEST HWY
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-3662
Practice Address - Country:US
Practice Address - Phone:708-262-4876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-24
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA11023000207Q00000X, 208D00000X
IL036.158544207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.158544OtherSTATE MEDICAL EXAMINER LICENSE
NJ25MA11023000OtherSTATE MEDICAL EXAMINER LICENSE