Provider Demographics
NPI:1225201767
Name:FAHIM K IBRAHIM M.D., P.C.
Entity Type:Organization
Organization Name:FAHIM K IBRAHIM M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HANIA
Authorized Official - Middle Name:
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-989-7702
Mailing Address - Street 1:4190 24TH AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3882
Mailing Address - Country:US
Mailing Address - Phone:810-989-7702
Mailing Address - Fax:810-989-7703
Practice Address - Street 1:4190 24TH AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3882
Practice Address - Country:US
Practice Address - Phone:810-989-7702
Practice Address - Fax:810-989-7703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-04
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIFI067033174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1807400741OtherBLUE CROSS
MI3350540Medicaid
MI180028723OtherPALMETTO GBA
MI0P24320Medicare PIN
MI3350540Medicaid