Provider Demographics
NPI:1023211422
Name:WARREN GASTROENTEROLOGY PC
Entity Type:Organization
Organization Name:WARREN GASTROENTEROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GHAITH
Authorized Official - Middle Name:M
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-757-6400
Mailing Address - Street 1:PO BOX 1920
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-1920
Mailing Address - Country:US
Mailing Address - Phone:586-757-6400
Mailing Address - Fax:
Practice Address - Street 1:27560 HOOVER RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-4505
Practice Address - Country:US
Practice Address - Phone:586-757-6400
Practice Address - Fax:586-757-8400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4813806Medicaid
MI0P48380Medicare PIN
MI4813806Medicaid