Healthcare Provider Details

I. General information

NPI: 1134118128
Provider Name (Legal Business Name): A GHAFOOR BAHA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 03/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 N STATE ROUTE 91 SUITE 250
PEORIA IL
61615-9541
US

IV. Provider business mailing address

8600 N STATE ROUTE 91 SUITE 250
PEORIA IL
61615-9541
US

V. Phone/Fax

Practice location:
  • Phone: 309-621-7001
  • Fax: 309-692-2538
Mailing address:
  • Phone: 309-621-7001
  • Fax: 309-692-2538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036101841
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number036101841
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: