Provider Demographics
NPI:1184610107
Name:IBRAHIM, LUCY (MD)
Entity type:Individual
Prefix:
First Name:LUCY
Middle Name:
Last Name:IBRAHIM
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 1:1401 LAKEWOOD DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-3352
Mailing Address - Country:US
Mailing Address - Phone:815-942-6323
Mailing Address - Fax:815-942-6423
Practice Address - Street 1:1280 WINDHAM PKWY
Practice Address - Street 2:
Practice Address - City:ROMEOVILLE
Practice Address - State:IL
Practice Address - Zip Code:60446-1673
Practice Address - Country:US
Practice Address - Phone:815-942-6323
Practice Address - Fax:815-942-6423
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0725592084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1626769OtherBCBS PROVIDER ID
IL036072559Medicaid
IL702080Medicare ID - Type UnspecifiedLOCALITY 15
IL260047252Medicare ID - Type UnspecifiedRR MEDICARE
IL1626769OtherBCBS PROVIDER ID