Basic Information
| Provider Information | |||||||||
| NPI: | 1851493803 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALI | ||||||||
| FirstName: | GHOLAM | ||||||||
| MiddleName: | HOSSAIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1430 TULANE AVE | ||||||||
| Address2: | SL-48 | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701122632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5049885152 | ||||||||
| FaxNumber: | 5049884237 | ||||||||
| Practice Location | |||||||||
| Address1: | 1415 TULANE AVE | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701122600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5049885152 | ||||||||
| FaxNumber: | 5049884237 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 01/20/2012 | ||||||||
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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 | 207RC0000X | 14879R | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 2145274 | 05 | LA | MEDICAID |