Provider Demographics
NPI:1851308910
Name:MUHAMMAD EJAZ ATA
Entity Type:Organization
Organization Name:MUHAMMAD EJAZ ATA
Other - Org Name:PISGAH MEDICAL CLINIC
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 2:6110 COUNTY ROAD 88
Mailing Address - City:PISGAH
Mailing Address - State:AL
Mailing Address - Zip Code:35765
Mailing Address - Country:US
Mailing Address - Phone:256-451-1250
Mailing Address - Fax:256-451-1270
Practice Address - Street 1:6110 COUNTY ROAD 88
Practice Address - Street 2:PISGAH MEDICAL CLINIC
Practice Address - City:PISGAH
Practice Address - State:AL
Practice Address - Zip Code:35765
Practice Address - Country:US
Practice Address - Phone:256-451-1250
Practice Address - Fax:256-451-1270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00000207R00000X
MI00000208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL011432OtherBLUE CROSS
AL541003864Medicaid
CM0511OtherRAILROAD MEDICACRE
AL102G704810Medicare PIN
ALH252Medicare PIN