Healthcare Provider Details

I. General information

NPI: 1639381817
Provider Name (Legal Business Name): MARYAM QURESHI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 09/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

241 W WEAVER RD SUITE 145D
FORSYTH IL
62535-9762
US

IV. Provider business mailing address

2300 N EDWARD ST GSBLL
DECATUR IL
62526-4163
US

V. Phone/Fax

Practice location:
  • Phone: 217-876-5250
  • Fax: 217-876-5255
Mailing address:
  • Phone: 217-876-2857
  • Fax: 217-876-2874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125-051850
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: