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General NPI Number Information
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NPI Number | 1912559691
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Entity Type | Individual
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Provider Name | ALI BALTAJI
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Gender | Male
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Dates
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Enumeration Date | 07/12/2019
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Last Update Date | 06/25/2024
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Provider Practice Location Address
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Address Line | 720 2ND AVE STE 203
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City | BOWLING GREEN
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State | KY
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Zip | 42101-1778
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Country | US
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Telephone | 270-843-5114
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Fax | 270-745-1230
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Provider Business Mailing Address
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Address Line | 720 2ND AVE STE 203
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City | BOWLING GREEN
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State | KY
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Zip | 42101-1778
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Country | US
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Telephone | 217-518-6382
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 125074501
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number | 59321
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License Number State | KY
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