Provider Demographics
NPI:1831293117
Name:MUHAMMAD EJAZ ATA, M.D
Entity Type:Organization
Organization Name:MUHAMMAD EJAZ ATA, M.D
Other - Org Name:PISGAH MEDICAL CLINIC SCOTTSBORO MEDICAL CLINIC MUHAMMAD EJAZ ATA MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MUHAMMAD
Authorized Official - Middle Name:EJAZ
Authorized Official - Last Name:ATA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-451-1250
Mailing Address - Street 1:PO BOX 246
Mailing Address - Street 2:
Mailing Address - City:PISGAH
Mailing Address - State:AL
Mailing Address - Zip Code:35765-0246
Mailing Address - Country:US
Mailing Address - Phone:256-451-1250
Mailing Address - Fax:256-451-1270
Practice Address - Street 1:506 HARLEY ST
Practice Address - Street 2:SCOTTSBORO MEDICAL CLINIC
Practice Address - City:SCOTTSBORO
Practice Address - State:AL
Practice Address - Zip Code:35768-4219
Practice Address - Country:US
Practice Address - Phone:256-574-6157
Practice Address - Fax:256-259-0560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL16386207R00000X
AL24327207R00000X
AL26901207R00000X
AL24797208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529900820Medicaid
ALCM0511OtherRAILROAD MEDICARE
AL102G704810Medicare PIN
ALH252Medicare PIN