Provider Demographics
NPI:1093747818
Name:ROSE M. IBRAHIM M.D. PC
Entity Type:Organization
Organization Name:ROSE M. IBRAHIM M.D. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-941-0895
Mailing Address - Street 1:1598 OLD CHATHAM DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-1040
Mailing Address - Country:US
Mailing Address - Phone:734-941-0895
Mailing Address - Fax:
Practice Address - Street 1:13739 S HURON RIVER DR
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-3628
Practice Address - Country:US
Practice Address - Phone:734-941-0895
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301046478208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1592176Medicaid
MI1592176Medicaid
MI0829551Medicare ID - Type Unspecified