=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942474127
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ESA M ALI MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2008
-----------------------------------------------------
Last Update Date | 04/02/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2590 ELIZABETH LAKE RD
-----------------------------------------------------
City | WATERFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48328-3314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-738-5500
-----------------------------------------------------
Fax | 248-738-5506
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2590 ELIZABETH LAKE RD
-----------------------------------------------------
City | WATERFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48328-3314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-738-5500
-----------------------------------------------------
Fax | 248-738-5506
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ESA M ALI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 248-738-5500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | EA076578
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------