Provider Demographics
NPI:1952807711
Name:MOUSA-IBRAHIM, FADY MOHAMMED (DO)
Entity type:Individual
Prefix:DR
First Name:FADY
Middle Name:MOHAMMED
Last Name:MOUSA-IBRAHIM
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:4201 W MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-8409
Mailing Address - Country:US
Mailing Address - Phone:815-759-4530
Mailing Address - Fax:815-759-8053
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-216-2687
Practice Address - Fax:708-216-5617
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL0361596882084A2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurocritical Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program