=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154330892
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOTT STREET MEDICAL, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1150 NOTT ST
-----------------------------------------------------
City | SCHENECTADY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12308-2426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-374-1655
-----------------------------------------------------
Fax | 518-374-1657
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1150 NOTT ST
-----------------------------------------------------
City | SCHENECTADY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12308-2426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-374-1655
-----------------------------------------------------
Fax | 518-374-1657
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER & SOLE MEMBER
-----------------------------------------------------
Name | DR. ALI MIRZA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 518-374-1655
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | NONE
-----------------------------------------------------
License Number State |
-----------------------------------------------------