Healthcare Provider Details

I. General information

NPI: 1164836722
Provider Name (Legal Business Name): TAHA IRFAN SYED D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W LAKE AVE STE 200
PEORIA IL
61614-5951
US

IV. Provider business mailing address

PO BOX 746715 FAPC
ATLANTA GA
30374-6715
US

V. Phone/Fax

Practice location:
  • Phone: 773-377-7304
  • Fax: 773-634-7965
Mailing address:
  • Phone: 773-377-7304
  • Fax: 773-634-7965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036143653
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: