Healthcare Provider Details

I. General information

NPI: 1700860822
Provider Name (Legal Business Name): MAHMOUD ISMAIL ALI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 05/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 HIGHWAY 77 STE C
PANAMA CITY FL
32405-4498
US

IV. Provider business mailing address

2810 HIGHWAY 77 STE C
PANAMA CITY FL
32405-4498
US

V. Phone/Fax

Practice location:
  • Phone: 850-818-0250
  • Fax: 850-818-0450
Mailing address:
  • Phone: 850-818-0250
  • Fax: 850-818-0450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number19091
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberA12287
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberME110173
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number25MA08875800
License Number StateNJ
# 5
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMASTER DEGREE
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: