Healthcare Provider Details

I. General information

NPI: 1356333033
Provider Name (Legal Business Name): ANSAR H ANSARI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 W WASHINGTON ST
PITTSFIELD IL
62363-1349
US

IV. Provider business mailing address

623 W WASHINGTON ST
PITTSFIELD IL
62363-1349
US

V. Phone/Fax

Practice location:
  • Phone: 217-285-4414
  • Fax: 217-285-5600
Mailing address:
  • Phone: 217-285-4414
  • Fax: 217-285-5600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: