Provider Demographics
NPI:1801863022
Name:EBRAHIMI, JEAN-MARIE R (MD)
Entity Type:Individual
Prefix:
First Name:JEAN-MARIE
Middle Name:R
Last Name:EBRAHIMI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7301 OHMS LANE
Mailing Address - Street 2:STE 650
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439
Mailing Address - Country:US
Mailing Address - Phone:952-835-9880
Mailing Address - Fax:952-857-1554
Practice Address - Street 1:7301 OHMS LANE
Practice Address - Street 2:STE 650
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439
Practice Address - Country:US
Practice Address - Phone:952-835-9880
Practice Address - Fax:952-857-1554
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26683207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN26683OtherMN MEDICAL LICENSE
MN595385500Medicaid
F49009Medicare UPIN
930000292Medicare ID - Type Unspecified