Provider Demographics
NPI:1508059072
Name:EBRAHEM, BAHAE MOHAMMED
Entity Type:Individual
Prefix:
First Name:BAHAE
Middle Name:MOHAMMED
Last Name:EBRAHEM
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 1:12815 NORTHLINE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-1109
Mailing Address - Country:US
Mailing Address - Phone:734-284-2090
Mailing Address - Fax:
Practice Address - Street 1:12815 NORTHLINE RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-1109
Practice Address - Country:US
Practice Address - Phone:734-284-2090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-19
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301089436207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI105222450Medicaid
MIMI5871001Medicare UPIN