Provider Demographics
NPI:1023112307
Name:ATA, MUHAMMAD EJAZ
Entity type:Individual
Prefix:
First Name:MUHAMMAD
Middle Name:EJAZ
Last Name:ATA
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:PO BOX 246
Mailing Address - Street 2:6110 COUNTY ROAD 88
Mailing Address - City:PISGAH
Mailing Address - State:AL
Mailing Address - Zip Code:35765-0246
Mailing Address - Country:US
Mailing Address - Phone:256-451-1250
Mailing Address - Fax:256-451-1270
Practice Address - Street 1:6110 COUNTY ROAD 88
Practice Address - Street 2:PISGAH MEDICAL CLINIC
Practice Address - City:PISGAH
Practice Address - State:AL
Practice Address - Zip Code:35765
Practice Address - Country:US
Practice Address - Phone:256-451-1250
Practice Address - Fax:256-451-1270
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-08
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL16386207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009910886Medicaid
AL110061830OtherRAILROAD MEDICARE
AL051523907OtherBLUE CROSS OF ALABAMA
AL000087667Medicaid
AL051087667OtherBLUE CROSS OF ALABAMA
AL529900820Medicaid
AL541003864Medicaid
AL541386401Medicaid
AL013935Medicare Oscar/Certification
AL051523907OtherBLUE CROSS OF ALABAMA
AL000087667Medicaid
F37062Medicare UPIN