MEDICARE: MARYAH MANSOOR MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	MD482769	PA
2	390200000X	Student in an Organized Health Care Education/Training Program
3	207RR0500X	Rheumatology Physician	C1-0011382	DE
4	207RR0500X	Rheumatology Physician	036172307	IL
5	207RR0500X	Rheumatology Physician	75524	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	75524	OTHER	MN	MD LICENSE

General Provider Information

NPI Number	:	1659684777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARYAH MANSOOR MD

Provider Business Mailing Address
First Line	:	1800 N KNOXVILLE AVE STE E
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61603-3005
Country	:	US
Telephone Number	:	309-308-0910
Fax Number	:	309-308-0919

Provider Business Practice Location Address
First Line	:	1800 N KNOXVILLE AVE STE E
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61603-3005
Country	:	US
Telephone Number	:	309-308-0910
Fax Number	:	309-308-0919

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2010
Last Update Date	:	04/10/2026

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Directions to “ MARYAH MANSOOR MD” Practice Location

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