Basic Information
| Provider Information | |||||||||
| NPI: | 1700028347 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALI | ||||||||
| FirstName: | FATIMA | ||||||||
| MiddleName: | SIDDIQUA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SIDDIQUA | ||||||||
| OtherFirstName: | FATIMA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5500 E KELLOGG | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 67218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166852221 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5500 E KELLOGG | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 67218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166852221 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2009 | ||||||||
| LastUpdateDate: | 02/07/2014 | ||||||||
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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 | 33044 | KS | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 04-33044 | KS | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200606990A | 05 | KS | MEDICAID |