Basic Information
| Provider Information | |||||||||
| NPI: | 1922210178 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIDDIQUI | ||||||||
| FirstName: | ALI | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4805 S MOORLAND RD | ||||||||
| Address2: | MOORLAND RESERVE | ||||||||
| City: | NEW BERLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531517401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627987200 | ||||||||
| FaxNumber: | 2627987201 | ||||||||
| Practice Location | |||||||||
| Address1: | 4805 S MOORLAND RD | ||||||||
| Address2: | MOORLAND RESERVE | ||||||||
| City: | NEW BERLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531517401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627987200 | ||||||||
| FaxNumber: | 2627987201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 02/01/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 336082767 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 65022 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0361214262 | 05 | IL | MEDICAID | P00968583 | 01 | IL | RRMCARE THRU CES | OTHER |