Basic Information
| Provider Information | |||||||||
| NPI: | 1518386093 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALI | ||||||||
| FirstName: | MARYYAM | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2854 HIGHWAY 55 STE 130 | ||||||||
| Address2: | |||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551211447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6518423349 | ||||||||
| FaxNumber: | 6518423391 | ||||||||
| Practice Location | |||||||||
| Address1: | 1997 SLOAN PL STE 17 | ||||||||
| Address2: | |||||||||
| City: | MAPLEWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517726251 | ||||||||
| FaxNumber: | 6512249661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2014 | ||||||||
| LastUpdateDate: | 10/08/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MT205639 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | 62073 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 1518386093 | 01 | NPI | OTHER | 62073 | 01 | MN | MN MEDICAL LICENSE | OTHER |