Healthcare Provider Details

I. General information

NPI: 1639666449
Provider Name (Legal Business Name): NUJUD ALI FARAG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

965 RIDGE LAKE BLVD # 315
MEMPHIS TN
38120-9401
US

IV. Provider business mailing address

2500 N STATE ST
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 877-348-1281
  • Fax: 901-227-3206
Mailing address:
  • Phone: 601-984-5514
  • Fax: 601-984-5503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License Number2022-01625
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: