Healthcare Provider Details

I. General information

NPI: 1659684777
Provider Name (Legal Business Name): MARYAH MANSOOR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2010
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 N KNOXVILLE AVE STE E
PEORIA IL
61603-3005
US

IV. Provider business mailing address

1800 N KNOXVILLE AVE STE E
PEORIA IL
61603-3005
US

V. Phone/Fax

Practice location:
  • Phone: 309-308-0910
  • Fax: 309-308-0919
Mailing address:
  • Phone: 309-308-0910
  • Fax: 309-308-0919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD482769
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberC1-0011382
License Number StateDE
# 4
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number036172307
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number75524
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: