1205883923 NPI number — MR. ALI AHMED JRADI DC

Table of content: MR. ALI AHMED JRADI DC (NPI 1205883923)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205883923 NPI number — MR. ALI AHMED JRADI DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JRADI
Provider First Name:
ALI
Provider Middle Name:
AHMED
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205883923
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2887 KRAFFT RD
Provider Second Line Business Mailing Address:
STE 1000
Provider Business Mailing Address City Name:
PORT HURON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-984-1994
Provider Business Mailing Address Fax Number:
810-984-3266

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2887 KRAFFT RD
Provider Second Line Business Practice Location Address:
STE 1000
Provider Business Practice Location Address City Name:
PORT HURON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-984-1994
Provider Business Practice Location Address Fax Number:
810-984-3266
Provider Enumeration Date:
05/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2301008995 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4776847 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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