Basic Information
| Provider Information | |||||||||
| NPI: | 1922530252 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IBIEBELE | ||||||||
| FirstName: | ABIYE | ||||||||
| MiddleName: | LAWRENCE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5301 MCAULEY DR | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481971051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347123456 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5301 MCAULEY DR | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481971051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347123000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2017 | ||||||||
| LastUpdateDate: | 10/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 287482 | MA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 125069944 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207XX0005X | 287482 | MA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207PS0010X | 4301507290 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Sports Medicine |
No ID Information.