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 1:4817 W 83RD ST
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:IL
Mailing Address - Zip Code:60459-2790
Mailing Address - Country:US
Mailing Address - Phone:708-262-4876
Mailing Address - Fax:708-810-6879
Practice Address - Street 1:4817 W 83RD ST
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:IL
Practice Address - Zip Code:60459-2790
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:2025-05-29
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