Provider Demographics
NPI:1598088171
Name:SHAHNAZ ALI, M.D. PLLC
Entity Type:Organization
Organization Name:SHAHNAZ ALI, M.D. PLLC
Other - Org Name:AGE MANAGEMENT & HORMONE BALANCE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAHNAZ
Authorized Official - Middle Name:
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-808-2695
Mailing Address - Street 1:PO BOX 289
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49429-0289
Mailing Address - Country:US
Mailing Address - Phone:616-457-9000
Mailing Address - Fax:616-457-3801
Practice Address - Street 1:1787 GRAND RIDGE CT NE
Practice Address - Street 2:STE 202
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-7042
Practice Address - Country:US
Practice Address - Phone:616-808-2695
Practice Address - Fax:616-808-2697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076867207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty