Healthcare Provider Details

I. General information

NPI: 1427346444
Provider Name (Legal Business Name): AMJAD MAHMOUD ABUALSUOD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2011
Last Update Date: 02/15/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5405 N KNOXVILLE AVE
PEORIA IL
61614-5016
US

IV. Provider business mailing address

5405 N KNOXVILLE AVE
PEORIA IL
61614-5016
US

V. Phone/Fax

Practice location:
  • Phone: 309-589-2050
  • Fax:
Mailing address:
  • Phone: 309-589-2050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036156509
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number01082223A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036156509
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number036156509
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: