Provider Demographics
NPI:1245336486
Name:IBRAHIM, SHARIQ M (MD)
Entity type:Individual
Prefix:
First Name:SHARIQ
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 1:8317 CALUMET AVE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-1737
Mailing Address - Country:US
Mailing Address - Phone:219-513-2333
Mailing Address - Fax:219-513-2333
Practice Address - Street 1:8317 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1737
Practice Address - Country:US
Practice Address - Phone:219-513-2333
Practice Address - Fax:219-513-2333
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062605A207L00000X, 208VP0014X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000494372OtherANTHEM BCBS
IN000000573813OtherANTHEM BC/BS OF INDIANA
IN200859300Medicaid
IN7163911OtherAETNA
IN000000573813OtherANTHEM BC/BS OF INDIANA
INI68319Medicare UPIN
IN148530GGMedicare PIN