Provider Demographics
NPI:1831648716
Name:DR.ALIF MANEJWALA
Entity Type:Organization
Organization Name:DR.ALIF MANEJWALA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NIKKI
Authorized Official - Middle Name:
Authorized Official - Last Name:ANSARI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-761-0507
Mailing Address - Street 1:1307 CRAIN HWY S
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-4024
Mailing Address - Country:US
Mailing Address - Phone:410-761-0507
Mailing Address - Fax:410-787-0857
Practice Address - Street 1:1307 CRAIN HWY S
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-4024
Practice Address - Country:US
Practice Address - Phone:410-761-0507
Practice Address - Fax:410-787-0857
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOLO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD29748261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD275781800Medicaid
MD1679681902OtherNPI
MD1679681902OtherNPI
MD1679681902Medicare NSC
MD1679681902Medicare Oscar/Certification
MD49259Medicare UPIN