Basic Information
| Provider Information | |||||||||
| NPI: | 1396907739 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ETHMANE ABOU EL MAALI | ||||||||
| FirstName: | CHEIKH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2501 N ORANGE AVE STE 401 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328044644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073037283 | ||||||||
| FaxNumber: | 4073030347 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 E ROLLINS ST | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328031248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073037283 | ||||||||
| FaxNumber: | 4073030347 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2008 | ||||||||
| LastUpdateDate: | 09/13/2018 | ||||||||
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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 | 207R00000X | 2008017229 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | ME130484 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 431560263 | 01 | MO | TRICARE | OTHER | P00712254 | 01 | MO | RR MCR | OTHER | 1396907739 | 05 | MO | MEDICAID | 176658001 | 05 | AR | MEDICAID |