Provider Demographics
NPI:1164088282
Name:ALI, MARIAM ISSAC
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:ISSAC
Last Name:ALI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6064 SOUTHPOINTE DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41005-8528
Mailing Address - Country:US
Mailing Address - Phone:619-822-5621
Mailing Address - Fax:
Practice Address - Street 1:6064 SOUTHPOINTE DR
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:KY
Practice Address - Zip Code:41005-8528
Practice Address - Country:US
Practice Address - Phone:619-822-5621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4720344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100592580Medicaid