MEDICARE: NOUR ALI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant

General Provider Information

NPI Number	:	1104279512
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NOUR ALI

Provider Business Mailing Address
First Line	:	115 LAKE VILLAGE BLVD
Second Line	:	APT 103
City	:	DEARBORN
State	:	MI
Zip	:	48120-1665
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	19145 ALLEN RD
Second Line	:	#107
City	:	BROWNSTOWN TWP
State	:	MI
Zip	:	48183-6812
Country	:	US
Telephone Number	:	734-486-4200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2016
Last Update Date	:	07/20/2016

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Directions to “ NOUR ALI ” Practice Location

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