Provider Demographics
NPI:1174523807
Name:ALI, AMJAD
Entity type:Individual
Prefix:
First Name:AMJAD
Middle Name:
Last Name:ALI
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 1:300 STATE ST
Mailing Address - Street 2:SUITE 400A
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1427
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 STATE ST
Practice Address - Street 2:SUITE 400A
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-1427
Practice Address - Country:US
Practice Address - Phone:814-877-6997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD425357208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1011424700001Medicaid
PA1650728OtherBLUE SHIELD
PAP00147185OtherRR MEDICARE
PA1011424700001Medicaid
WV1068907OtherWV WORKERS COMP
PA410346OtherUPMC
NY02601921OtherNY MEDICAID
PA159453OtherUNISON
OH2608164OtherOH MEDICAL ASSISTANCE
PA1537326OtherGATEWAY
NY00027031701OtherUNIVERA
NY02601921OtherNY MEDICAID