Provider Demographics
NPI:1578562781
Name:IBRAHIM, HASSAN A (MD)
Entity Type:Individual
Prefix:DR
First Name:HASSAN
Middle Name:A
Last Name:IBRAHIM
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:PO BOX 518
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-0518
Mailing Address - Country:US
Mailing Address - Phone:708-614-3000
Mailing Address - Fax:708-614-3006
Practice Address - Street 1:16650 HARLEM AVE
Practice Address - Street 2:SUITE C
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-1847
Practice Address - Country:US
Practice Address - Phone:708-614-3000
Practice Address - Fax:708-614-3006
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088992207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088992Medicaid
ILF85191Medicare UPIN
IL566770Medicare PIN
IL036088992Medicaid