Provider Demographics
NPI:1538944509
Name:ALI, MOHAMED TAYEB ELASMA MOHAMED (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMED
Middle Name:TAYEB ELASMA MOHAMED
Last Name:ALI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7489 TROUTWOOD DR APT 2A
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-7503
Mailing Address - Country:US
Mailing Address - Phone:810-919-1234
Mailing Address - Fax:
Practice Address - Street 1:HURLEY MEDICAL CENTER, PEDIATRIC EDUCATION 6A
Practice Address - Street 2:ATTN: AUDRINA ROBERTS
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503
Practice Address - Country:US
Practice Address - Phone:810-262-7045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351051022390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program