Provider Demographics
NPI:1326018748
Name:ALI, FATHELRAHMAN OMER (MD)
Entity Type:Individual
Prefix:
First Name:FATHELRAHMAN
Middle Name:OMER
Last Name:ALI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2040 MONROE ST
Mailing Address - Street 2:SUITE # 207
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2950
Mailing Address - Country:US
Mailing Address - Phone:313-278-5836
Mailing Address - Fax:313-278-5846
Practice Address - Street 1:2040 MONROE ST
Practice Address - Street 2:SUITE # 207
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2950
Practice Address - Country:US
Practice Address - Phone:313-278-5836
Practice Address - Fax:313-278-5846
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301075097207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4787887Medicaid
H67224Medicare UPIN
MI4787887Medicaid