Provider Demographics
NPI:1528055662
Name:ALI, SYED A (MD)
Entity type:Individual
Prefix:
First Name:SYED
Middle Name:A
Last Name:ALI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 467
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47601-0467
Mailing Address - Country:US
Mailing Address - Phone:812-897-4458
Mailing Address - Fax:812-897-5977
Practice Address - Street 1:1301 MILLIS AVE
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47601-2329
Practice Address - Country:US
Practice Address - Phone:812-897-4458
Practice Address - Fax:812-897-5977
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026430A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100254090Medicaid
IN880570AMedicare ID - Type Unspecified
IN100254090Medicaid