| Glen Avenue Family Practice | |
|
4930 N Executive Dr Peoria IL 61614-4894 | |
| (309) 692-7575 | |
| Not Available |
| Full Name | Glen Avenue Family Practice |
|---|---|
| Speciality | General Practice |
| Location | 4930 N Executive Dr, Peoria, Illinois |
| Authorized Official Name and Position | Susan Lafollette (BILLING MANAGER) |
| Authorized Official Contact | 3096718749 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Glen Avenue Family Practice 4930 N Executive Dr Peoria IL 61614-4894 Ph: (309) 692-7575 | Glen Avenue Family Practice 4930 N Executive Dr Peoria IL 61614-4894 Ph: (309) 692-7575 |
| NPI Number | 1689896961 |
|---|---|
| Provider Enumeration Date | 05/03/2007 |
| Last Update Date | 06/30/2008 |
| Medicare PECOS PAC ID | 3678594777 |
|---|---|
| Medicare Enrollment ID | O20051216000498 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1689896961 | NPI | - | NPPES |
| 212719 | Other | IL | MEDICARE GROUP ID |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 208D00000X | General Practice | 036067626 (Illinois) | Primary |
| Provider Name | Syed Masood Ali |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1700805439 PECOS PAC ID: 2769403864 Enrollment ID: I20051216000549 |
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