Provider Demographics
NPI:1053517540
Name:SOUEIDAN, ALI (MD)
Entity type:Individual
Prefix:
First Name:ALI
Middle Name:
Last Name:SOUEIDAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 S TRUMBULL ST
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708-7656
Mailing Address - Country:US
Mailing Address - Phone:989-893-7460
Mailing Address - Fax:989-895-5813
Practice Address - Street 1:640 S TRUMBULL ST
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-7656
Practice Address - Country:US
Practice Address - Phone:989-893-7460
Practice Address - Fax:989-895-5813
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24151207RC0200X, 207RP1001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810018693Medicaid
P00858195OtherMEDICARE RAILROAD
P00858195OtherMEDICARE RAILROAD