Provider Demographics
NPI:1942474127
Name:ESA M ALI MD PC
Entity type:Organization
Organization Name:ESA M ALI MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ESA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-738-5500
Mailing Address - Street 1:2590 ELIZABETH LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-3314
Mailing Address - Country:US
Mailing Address - Phone:248-738-5500
Mailing Address - Fax:248-738-5506
Practice Address - Street 1:2590 ELIZABETH LAKE RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-3314
Practice Address - Country:US
Practice Address - Phone:248-738-5500
Practice Address - Fax:248-738-5506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIEA076578207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI6010Medicare PIN