Provider Demographics
NPI:1144216649
Name:AL-MUDAMGHA, ALI A (MD)
Entity Type:Individual
Prefix:
First Name:ALI
Middle Name:A
Last Name:AL-MUDAMGHA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4820 W TAFT RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-2800
Mailing Address - Country:US
Mailing Address - Phone:315-448-6215
Mailing Address - Fax:315-234-4416
Practice Address - Street 1:4820 W TAFT RD
Practice Address - Street 2:SUITE 209
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-2800
Practice Address - Country:US
Practice Address - Phone:315-448-6215
Practice Address - Fax:315-234-4416
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY187031207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01742805Medicaid
NY01742805Medicaid
RB7793Medicare PIN
G37280Medicare UPIN
BB7132Medicare PIN