Provider Demographics
NPI:1275709511
Name:IBRAHIM WILLIAM SIDHOM M.D.,P.C.
Entity Type:Organization
Organization Name:IBRAHIM WILLIAM SIDHOM M.D.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IBRAHIM
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:SIDHOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-541-5595
Mailing Address - Street 1:48 PULASKI AVE
Mailing Address - Street 2:
Mailing Address - City:CARTERET
Mailing Address - State:NJ
Mailing Address - Zip Code:07008-2509
Mailing Address - Country:US
Mailing Address - Phone:732-541-5595
Mailing Address - Fax:
Practice Address - Street 1:48 PULASKI AVE
Practice Address - Street 2:
Practice Address - City:CARTERET
Practice Address - State:NJ
Practice Address - Zip Code:07008-2509
Practice Address - Country:US
Practice Address - Phone:732-541-5595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA50525261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7530803Medicaid
F82827Medicare UPIN