Healthcare Provider Details

I. General information

NPI: 1003102898
Provider Name (Legal Business Name): ALI KASSAMALI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2011
Last Update Date: 07/09/2020
Certification Date: 07/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 TOWER RD NE STE 350
MARIETTA GA
30060-9415
US

IV. Provider business mailing address

3390 PEACHTREE RD NE STE 1500
ATLANTA GA
30326-2822
US

V. Phone/Fax

Practice location:
  • Phone: 404-920-4950
  • Fax: 404-920-4959
Mailing address:
  • Phone: 404-920-4950
  • Fax: 770-252-7513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code193400000X
TaxonomySingle Specialty Group
License Number076333
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number076333
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTRN16412
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number076333
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: