Provider Demographics
NPI:1831478627
Name:ELEMO, IBRAHIM AMAE (MD)
Entity Type:Individual
Prefix:DR
First Name:IBRAHIM
Middle Name:AMAE
Last Name:ELEMO
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 1:1800 E LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3810
Mailing Address - Country:US
Mailing Address - Phone:217-464-5811
Mailing Address - Fax:217-464-1318
Practice Address - Street 1:1800 E LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3810
Practice Address - Country:US
Practice Address - Phone:217-464-5811
Practice Address - Fax:217-464-1318
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-10
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036134398208M00000X, 207R00000X
MN61530208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist