Healthcare Provider Details

I. General information

NPI: 1962029199
Provider Name (Legal Business Name): AHMED SOUKAT ALI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2020
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 E STATE ST
ROCKFORD IL
61104-2298
US

IV. Provider business mailing address

1401 E STATE ST
ROCKFORD IL
61104-2298
US

V. Phone/Fax

Practice location:
  • Phone: 779-696-4400
  • Fax: 315-464-3751
Mailing address:
  • Phone: 779-696-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036.164942
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: