Provider Demographics
NPI:1245527845
Name:SALLOUM, IBRAHEM (MD)
Entity type:Individual
Prefix:
First Name:IBRAHEM
Middle Name:
Last Name:SALLOUM
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 1:825 CHALKSTONE AVE
Mailing Address - Street 2:GRADUATE MEDICAL EDUCATION
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-4728
Mailing Address - Country:US
Mailing Address - Phone:401-588-4001
Mailing Address - Fax:
Practice Address - Street 1:164 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2853
Practice Address - Country:US
Practice Address - Phone:401-793-4489
Practice Address - Fax:401-793-4047
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-02
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP02361207R00000X
RIMD14622207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine