Healthcare Provider Details

I. General information

NPI: 1013392018
Provider Name (Legal Business Name): ALI RAZA GHANI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2015
Last Update Date: 12/24/2025
Certification Date: 12/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 FRANKLIN AVE STE 4500
NORMAL IL
61761-3593
US

IV. Provider business mailing address

PO BOX 18892
BELFAST ME
04915-4083
US

V. Phone/Fax

Practice location:
  • Phone: 309-556-8300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number036165609
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036165609
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number77437
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: