Provider Demographics
NPI:1912559691
Name:BALTAJI, ALI
Entity type:Individual
Prefix:
First Name:ALI
Middle Name:
Last Name:BALTAJI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 2ND AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1778
Mailing Address - Country:US
Mailing Address - Phone:217-518-6382
Mailing Address - Fax:
Practice Address - Street 1:720 2ND AVE STE 203
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1778
Practice Address - Country:US
Practice Address - Phone:270-843-5114
Practice Address - Fax:270-745-1230
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125074501207R00000X
KY59321207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100981060Medicaid