Healthcare Provider Details

I. General information

NPI: 1922348101
Provider Name (Legal Business Name): SARAH ALI TARIQ DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2013
Last Update Date: 02/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W MAIN ST
MARION IL
62959-1188
US

IV. Provider business mailing address

181 STONE LAKE DR
MAKANDA IL
62958-2751
US

V. Phone/Fax

Practice location:
  • Phone: 618-997-5311
  • Fax:
Mailing address:
  • Phone: 708-712-9554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number266013-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: