Basic Information
| Provider Information | |||||||||
| NPI: | 1174797203 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GHOBRIAL | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24701 EUCLID AVE | ||||||||
| Address2: | THIRD FLOOR BILLING SERVICES | ||||||||
| City: | EUCLID | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441171714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165935500 | ||||||||
| FaxNumber: | 2168445922 | ||||||||
| Practice Location | |||||||||
| Address1: | 3999 RICHMOND RD | ||||||||
| Address2: | |||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441226046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165935500 | ||||||||
| FaxNumber: | 2168445922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2008 | ||||||||
| LastUpdateDate: | 07/01/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0202X | 35-120971 | OH | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0083865 | 05 | OH | MEDICAID |