Basic Information
| Provider Information | |||||||||
| NPI: | 1063428217 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL INDIANA PHYSICAL MEDICINE & REHAB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 N GRANVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473032110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652133238 | ||||||||
| FaxNumber: | 7652842434 | ||||||||
| Practice Location | |||||||||
| Address1: | 1107 S TILLOTSON AVE | ||||||||
| Address2: | STE 1 | ||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473044517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652133024 | ||||||||
| FaxNumber: | 7652829303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 01/16/2020 | ||||||||
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| AuthorizedOfficialLastName: | IBRAHIM | ||||||||
| AuthorizedOfficialFirstName: | MIRIAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7652133024 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 01/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.