Provider Demographics
NPI:1033159629
Name:IBRAHIM, FADI
Entity Type:Individual
Prefix:DR
First Name:FADI
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7550 WOLF RIVER BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-1778
Mailing Address - Country:US
Mailing Address - Phone:901-542-6845
Mailing Address - Fax:901-542-6890
Practice Address - Street 1:7550 WOLF RIVER BLVD STE 200
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1778
Practice Address - Country:US
Practice Address - Phone:901-542-6845
Practice Address - Fax:901-542-6890
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN40377174400000X, 207ZP0101X
CAA93586174400000X
WV22149174400000X
VA0101237736174400000X
IN01061271 A174400000X
MI4301085213174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No174400000XOther Service ProvidersSpecialist