Basic Information
| Provider Information | |||||||||
| NPI: | 1891701082 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IBRAHIM | ||||||||
| FirstName: | MOHAMMED | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29992 NORTHWESTERN HWY STE C | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483343292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488511430 | ||||||||
| FaxNumber: | 2488515182 | ||||||||
| Practice Location | |||||||||
| Address1: | 3577 W 13 MILE RD STE 103 | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480736710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482884500 | ||||||||
| FaxNumber: | 2482880450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 04/25/2019 | ||||||||
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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 | 207RH0003X | 4301081380 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | MI4989559 | 01 | MI | MEDICARE PTAN | OTHER | 1891701082 | 05 | MI | MEDICAID |