Healthcare Provider Details

I. General information

NPI: 1992770101
Provider Name (Legal Business Name): SOHAIL ABID SIDDIQUE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 N 9TH ST STE 6W100
SPRINGFIELD IL
62702-5303
US

IV. Provider business mailing address

415 N 9TH ST PO BOX 19640
SPRINGFIELD IL
62702-5303
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-545-4912
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-545-4912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036-122458
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number036-122458
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: