Provider Demographics
NPI:1174613418
Name:HAIDER, SHAN E ALI (MD)
Entity type:Individual
Prefix:
First Name:SHAN E ALI
Middle Name:
Last Name:HAIDER
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 1:20410 OBSERVATION DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20876-4000
Mailing Address - Country:US
Mailing Address - Phone:301-330-1000
Mailing Address - Fax:301-330-9108
Practice Address - Street 1:20410 OBSERVATION DR
Practice Address - Street 2:SUITE 100
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20876-4000
Practice Address - Country:US
Practice Address - Phone:301-330-1000
Practice Address - Fax:301-330-9108
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD428261207RC0200X
MDD00662762086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD056151700Medicaid
DC022451H49Medicare PIN
MD056151700Medicaid