Basic Information
| Provider Information | |||||||||
| NPI: | 1053407775 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALMUDALLAL | ||||||||
| FirstName: | ALI | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636930 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636930 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 770 W HIGH ST | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458013990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199965224 | ||||||||
| FaxNumber: | 4199965276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 01/04/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 35076642 | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0600X | 35076642 | OH | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology |
ID Information
| ID | Type | State | Issuer | Description | 2249696 | 05 | OH | MEDICAID |