Provider Demographics
NPI:1649381369
Name:IBRAHIMA PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:IBRAHIMA PHYSICAL THERAPY INC
Other - Org Name:CORPORATION
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:IBRAHIMA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIALLO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:301-446-1724
Mailing Address - Street 1:803 MANOR HOUSE DRIVE
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774
Mailing Address - Country:US
Mailing Address - Phone:301-446-1724
Mailing Address - Fax:301-446-1726
Practice Address - Street 1:7315 B HANOVER PARKWAY
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770
Practice Address - Country:US
Practice Address - Phone:301-446-1724
Practice Address - Fax:301-446-1726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19812225100000X
DC870275225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG01610Medicare ID - Type Unspecified