Basic Information
Provider Information | |||||||||
NPI: | 1578885315 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | IBRAHIM | ||||||||
FirstName: | SAAD | ||||||||
MiddleName: | M. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D., M.S. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 80070 | ||||||||
Address2: |   | ||||||||
City: | FORT WAYNE | ||||||||
State: | IN | ||||||||
PostalCode: | 468980070 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2604321568 | ||||||||
FaxNumber: | 2604324969 | ||||||||
Practice Location | |||||||||
Address1: | 7950 W JEFFERSON BLVD | ||||||||
Address2: |   | ||||||||
City: | FORT WAYNE | ||||||||
State: | IN | ||||||||
PostalCode: | 468044140 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2604321568 | ||||||||
FaxNumber: | 2604324969 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/22/2010 | ||||||||
LastUpdateDate: | 03/23/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 01077855A | IN | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 01077855A | IN | N |   | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
ID | Type | State | Issuer | Description | 0202979 | 05 | OH |   | MEDICAID | 201407460 | 05 | IN |   | MEDICAID |