Provider Demographics
NPI:1518386093
Name:ALI, MARYYAM (MD)
Entity type:Individual
Prefix:
First Name:MARYYAM
Middle Name:
Last Name:ALI
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:2854 HIGHWAY 55 STE 130
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-1447
Mailing Address - Country:US
Mailing Address - Phone:651-842-3349
Mailing Address - Fax:651-842-3391
Practice Address - Street 1:1997 SLOAN PL STE 17
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55117
Practice Address - Country:US
Practice Address - Phone:651-772-6251
Practice Address - Fax:651-224-9661
Is Sole Proprietor?:No
Enumeration Date:2014-04-10
Last Update Date:2019-10-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMT205639207R00000X
MN62073207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1518386093OtherNPI
MN62073OtherMN MEDICAL LICENSE