Basic Information
| Provider Information | |||||||||
| NPI: | 1144216649 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AL-MUDAMGHA | ||||||||
| FirstName: | ALI | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4820 W TAFT RD | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | LIVERPOOL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130882800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154486215 | ||||||||
| FaxNumber: | 3152344416 | ||||||||
| Practice Location | |||||||||
| Address1: | 4820 W TAFT RD | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | LIVERPOOL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130882800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154486215 | ||||||||
| FaxNumber: | 3152344416 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 05/29/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 187031 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0001X | 187031 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology |
ID Information
| ID | Type | State | Issuer | Description | 01742805 | 05 | NY | MEDICAID |