Basic Information
| Provider Information | |||||||||
| NPI: | 1396017984 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IBRAHIM | ||||||||
| FirstName: | ABBAS | ||||||||
| MiddleName: | M.B | ||||||||
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| NameSuffix: | SR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10600 BROOKS LANE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087173841 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12935 S GREGORY STREET | ||||||||
| Address2: | |||||||||
| City: | BLUE ISLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085972000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2012 | ||||||||
| LastUpdateDate: | 01/30/2012 | ||||||||
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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 | 363AS0400X | 238.000314 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.