Basic Information
| Provider Information | |||||||||
| NPI: | 1972937480 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SABEEHA HAQUE ALI MD LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RIVERVIEW PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 102 N LOGAN AVE | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618328513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174425863 | ||||||||
| FaxNumber: | 2174425040 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 N LOGAN AVE | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618328513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174425863 | ||||||||
| FaxNumber: | 2174425040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2013 | ||||||||
| LastUpdateDate: | 11/12/2013 | ||||||||
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| AuthorizedOfficialLastName: | HAQUE | ||||||||
| AuthorizedOfficialFirstName: | SABEEHA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3125459727 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 036109029 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 3426615776045330 | 05 | IL | MEDICAID |