Basic Information
| Provider Information | |||||||||
| NPI: | 1437563947 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AL ALI | ||||||||
| FirstName: | FEDA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 743904 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303743904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967320 | ||||||||
| FaxNumber: | 8032967330 | ||||||||
| Practice Location | |||||||||
| Address1: | 14 RICHLAND MEDICAL PARK DR STE 320 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034346771 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2014 | ||||||||
| LastUpdateDate: | 07/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME131866 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 4301105526 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 52362 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4301105526 | 01 | MI | LICENSING AND REGULATORY AFFAIRS | OTHER | 523623 | 05 | SC | MEDICAID | 020595700 | 05 | FL | MEDICAID |