Provider Demographics
NPI:1356452833
Name:AL-SANOURI, IBRAHIM (MD)
Entity Type:Individual
Prefix:DR
First Name:IBRAHIM
Middle Name:
Last Name:AL-SANOURI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:G3252 BEECHER RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3614
Mailing Address - Country:US
Mailing Address - Phone:810-230-6800
Mailing Address - Fax:810-230-0713
Practice Address - Street 1:700 S PARK ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1830
Practice Address - Country:US
Practice Address - Phone:608-251-6100
Practice Address - Fax:608-258-5222
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301075454207K00000X, 207RC0200X
WI51402207RP1001X
MI4301075451207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1356452833Medicaid