Healthcare Provider Details

I. General information

NPI: 1144216649
Provider Name (Legal Business Name): ALI A AL-MUDAMGHA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4939 BRITTONFIELD PKWY STE 202
EAST SYRACUSE NY
13057-9208
US

IV. Provider business mailing address

301 PROSPECT AVE # MSO
SYRACUSE NY
13203-1807
US

V. Phone/Fax

Practice location:
  • Phone: 315-634-6699
  • Fax: 315-744-1921
Mailing address:
  • Phone: 315-448-5881
  • Fax: 315-448-3548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number187031
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number187031
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: