MEDICARE: AHMED H ALY-ABDEL-LATIF RN

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	163W00000X	Registered Nurse	4704293356	MI
2	367500000X	Certified Registered Nurse Anesthetist	4704293356	MI

General Provider Information

NPI Number	:	1619549482
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AHMED H ALY-ABDEL-LATIF RN

Provider Business Mailing Address
First Line	:	5146 PARKSIDE DR
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48323-2169
Country	:	US
Telephone Number	:	313-434-6667
Fax Number	:

Provider Business Practice Location Address
First Line	:	5146 PARKSIDE DR
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48323-2169
Country	:	US
Telephone Number	:	313-434-6667
Fax Number	:

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

Provider Enumeration Date	:	07/12/2021
Last Update Date	:	12/24/2024

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