Organization
SYED MASOOD ALI, MDSC
Active
Other names
Glen Avenue Family Practice
Organization subpart
No
Provider details
NPI number
Authorized official
SUSAN LAFOLLETTE (BILLING MANAGER)
(309) 671-8749
Entity
Organization
Contact information
Practice address
4930 N EXECUTIVE DR, PEORIA, IL 61614-4894
(309) 692-7575
Mailing address
4930 N EXECUTIVE DR, PEORIA, IL 61614-4894
(309) 692-7575
Taxonomy
Speciality
Code
Description
License number
State
208D00000X
General Practice Physician
Primary
036067626
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
212719
MEDICARE GROUP ID
IL
Enumeration date
05/03/2007
Last updated
06/30/2008
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