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General NPI Number Information
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NPI Number | 1659684777
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Entity Type | Individual
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Provider Name | MARYAH MANSOOR MD
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Gender | Female
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Dates
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Enumeration Date | 07/18/2010
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Last Update Date | 10/17/2024
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Provider Practice Location Address
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Address Line | 1800 N KNOXVILLE AVE STE E
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City | PEORIA
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State | IL
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Zip | 61603-3005
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Country | US
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Telephone | 309-308-0910
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Fax | 309-308-0919
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Provider Business Mailing Address
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Address Line | 1800 N KNOXVILLE AVE STE E
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City | PEORIA
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State | IL
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Zip | 61603-3005
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Country | US
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Telephone | 309-308-0910
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Fax | 309-308-0919
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RR0500X
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Taxonomy Name | Rheumatology Physician
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License Number | C1-0011382
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License Number State | DE
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207RR0500X
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Taxonomy Name | Rheumatology Physician
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License Number | 036172307
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License Number State | IL
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Taxonomy #4
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Taxonomy Code | 207RR0500X
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Taxonomy Name | Rheumatology Physician
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License Number | 75524
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License Number State | MN
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