Basic Information
| Provider Information | |||||||||
| NPI: | 1992770101 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIDDIQUE | ||||||||
| FirstName: | SOHAIL | ||||||||
| MiddleName: | ABID | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 N 9TH ST | ||||||||
| Address2: | PO BOX 19640 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627025303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175458000 | ||||||||
| FaxNumber: | 2175454912 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 N 9TH ST | ||||||||
| Address2: | STE 6W100 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627025303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175458000 | ||||||||
| FaxNumber: | 2175454912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 12/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 036-122458 | IL | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VF0040X | 036-122458 | IL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Female Pelvic Medicine and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 036122458 | 05 | IL | MEDICAID |