Provider Demographics
NPI:1932113438
Name:IBRAHIM, GHAITH M (MD)
Entity Type:Individual
Prefix:DR
First Name:GHAITH
Middle Name:M
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 1920
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-1920
Mailing Address - Country:US
Mailing Address - Phone:586-757-6400
Mailing Address - Fax:
Practice Address - Street 1:27560 HOOVER ROAD
Practice Address - Street 2:HOOVER MEDICAL PLAZA
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093
Practice Address - Country:US
Practice Address - Phone:586-757-6400
Practice Address - Fax:586-757-8400
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIGI071013207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4813806Medicaid
MI4813806Medicaid
G84226Medicare UPIN