Provider Demographics
NPI:1053835090
Name:IBRAHIM, FAISAL ABDELAZIZ
Entity Type:Individual
Prefix:
First Name:FAISAL
Middle Name:ABDELAZIZ
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:FAISAL
Other - Middle Name:
Other - Last Name:IBRAHIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:201 E MADISON ST STE 328
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-5131
Mailing Address - Country:US
Mailing Address - Phone:217-545-3787
Mailing Address - Fax:
Practice Address - Street 1:751 N RUTLEDGE ST STE 3100
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4968
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-7363
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1250713822084N0400X
IL036.1560172084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology