Provider Demographics
NPI:1336102219
Name:GHOBRIAL, IBRAHIM
Entity Type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:
Last Name:GHOBRIAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 5TH AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MCKEESPORT
Mailing Address - State:PA
Mailing Address - Zip Code:15132-2422
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 5TH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:MCKEESPORT
Practice Address - State:PA
Practice Address - Zip Code:15132-2422
Practice Address - Country:US
Practice Address - Phone:412-664-2784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD56184L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAG15919Medicare UPIN
PA802436Medicare ID - Type Unspecified