Provider Demographics
NPI:1598739617
Name:ALI, AMJAD (MD)
Entity Type:Individual
Prefix:
First Name:AMJAD
Middle Name:
Last Name:ALI
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 1:740 E LAUREL RD
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-8601
Mailing Address - Country:US
Mailing Address - Phone:606-877-3931
Mailing Address - Fax:606-877-3978
Practice Address - Street 1:310 E 9TH ST
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741
Practice Address - Country:US
Practice Address - Phone:606-878-6520
Practice Address - Fax:606-877-3978
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01081762A207R00000X, 208M00000X
KY34288208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64027303Medicaid
KY611427889OtherBLUEGRASS FAMILY HEALTHCA
KYK237232OtherMEDICARE
KY030670000OtherBLACK LUNG
KY611427889OtherUNITED HEALTHCARE
KY50005623OtherPASSPORT HEALTHCARE
KYC72032OtherCUMBERLAND HEALTHCARE INC
KY611427889OtherCHA
KY611427889OtherHUMANA
KY930124013OtherRAILROAD MEDICARE
KY000000377977OtherANTHEM PROVIDER #
KY611427889OtherTRICARE
KYG94807Medicare UPIN