Provider Demographics
NPI:1073940078
Name:AVICENNA MEDICAL GROUP
Entity type:Organization
Organization Name:AVICENNA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ABDALLAH
Authorized Official - Middle Name:Y
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-334-7173
Mailing Address - Street 1:16453 PEARL RD
Mailing Address - Street 2:
Mailing Address - City:STRONGSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44136-6041
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16453 PEARL RD
Practice Address - Street 2:
Practice Address - City:STRONGSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44136-6041
Practice Address - Country:US
Practice Address - Phone:440-334-7173
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-04
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care