Provider Demographics
NPI:1396746822
Name:GHABRA, MOHAMMED B (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMMED
Middle Name:B
Last Name:GHABRA
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 1:12632 S HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1428
Mailing Address - Country:US
Mailing Address - Phone:708-587-0000
Mailing Address - Fax:
Practice Address - Street 1:12632 S HARLEM AVE
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463
Practice Address - Country:US
Practice Address - Phone:708-587-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0900162084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036090016Medicaid
IL036090016Medicaid
ILK52582Medicare PIN
ILG80861Medicare UPIN
IL036-090016-2Medicaid
IL036090016Medicaid
ILK52581Medicare PIN
ILP00427367Medicare PIN