Basic Information
| Provider Information | |||||||||
| NPI: | 1114371481 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EMAD IBRAHIM, MD, INC. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 527 ACACIA CT | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923735667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095573983 | ||||||||
| FaxNumber: | 9093356162 | ||||||||
| Practice Location | |||||||||
| Address1: | 245 TERRACINA BLVD STE 206 | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923734867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097934336 | ||||||||
| FaxNumber: | 9097933325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2016 | ||||||||
| LastUpdateDate: | 07/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | IBRAHIM | ||||||||
| AuthorizedOfficialFirstName: | EMAD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9095573983 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 07/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0200X | A51062 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Oncology |
ID Information
| ID | Type | State | Issuer | Description | 00A510620 | 05 | CA | MEDICAID |