Provider Demographics
NPI:1134119001
Name:IBRAHIM MD SC
Entity Type:Organization
Organization Name:IBRAHIM MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HASSAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-342-1541
Mailing Address - Street 1:PO BOX 747
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60412-0747
Mailing Address - Country:US
Mailing Address - Phone:708-747-5850
Mailing Address - Fax:708-747-9991
Practice Address - Street 1:6703 159TH ST
Practice Address - Street 2:SUITE 105
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-1781
Practice Address - Country:US
Practice Address - Phone:708-342-1541
Practice Address - Fax:708-342-2673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00021623342OtherBCBSIL GROUP NUMBER
00021623342OtherBCBSIL GROUP NUMBER