Provider Demographics
NPI:1639676596
Name:S T IBRAHIM MEDICAL P.C
Entity Type:Organization
Organization Name:S T IBRAHIM MEDICAL P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SYED
Authorized Official - Middle Name:TARIQ
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-221-8225
Mailing Address - Street 1:112 KNICKERBOCKER RD
Mailing Address - Street 2:
Mailing Address - City:DEMAREST
Mailing Address - State:NJ
Mailing Address - Zip Code:07627-1026
Mailing Address - Country:US
Mailing Address - Phone:856-221-8225
Mailing Address - Fax:201-331-3637
Practice Address - Street 1:112 KNICKERBOCKER RD
Practice Address - Street 2:
Practice Address - City:DEMAREST
Practice Address - State:NJ
Practice Address - Zip Code:07627-1026
Practice Address - Country:US
Practice Address - Phone:856-221-8225
Practice Address - Fax:201-331-3637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty