MEDICARE: ALI IBRAHIM NASRALLAH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	4351038938	MI

General Provider Information

NPI Number	:	1972096261
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALI IBRAHIM NASRALLAH

Provider Business Mailing Address
First Line	:	25350 W WARREN ST
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48127-2102
Country	:	US
Telephone Number	:	313-914-3666
Fax Number	:

Provider Business Practice Location Address
First Line	:	25350 W WARREN ST
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48127-2102
Country	:	US
Telephone Number	:	313-914-3666
Fax Number	:	313-380-0672

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2018
Last Update Date	:	12/05/2022

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