Healthcare Provider Details

I. General information

NPI: 1619319472
Provider Name (Legal Business Name): ALI SHABAHANG SABER TEHRANI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2013
Last Update Date: 04/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N WOLFE STREET PHIPPS BUILDING, SUITE 793
BALITMORE MD
21287
US

IV. Provider business mailing address

600 N. WOLFE STREET, PHIPPS BUILDING, PHIPPS BUILDING, SUITE 493
BALTIMORE MD
21287
US

V. Phone/Fax

Practice location:
  • Phone: 309-655-2702
  • Fax:
Mailing address:
  • Phone: 410-955-2228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number125064269
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberD0085132
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: