Basic Information
| Provider Information | |||||||||
| NPI: | 1518237585 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALI | ||||||||
| FirstName: | MIR | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 HOLLISTER DR STE 112 | ||||||||
| Address2: | |||||||||
| City: | LIBERTYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600485265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473676781 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1800 HOLLISTER DR STE 112 | ||||||||
| Address2: | |||||||||
| City: | LIBERTYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600485265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473676781 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2012 | ||||||||
| LastUpdateDate: | 12/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01070723A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 148315 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 276959 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0003X | 036.152740 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 201060520 | 05 | IN | MEDICAID |