Basic Information
| Provider Information | |||||||||
| NPI: | 1932562089 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ABDEL-RAHMAN | ||||||||
| FirstName: | ISLAM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 W WHITE RIVER BLVD | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473034988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7647474492 | ||||||||
| FaxNumber: | 3172222126 | ||||||||
| Practice Location | |||||||||
| Address1: | 5165 MCCARTY LN | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479058764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654488000 | ||||||||
| FaxNumber: | 7658684698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2016 | ||||||||
| LastUpdateDate: | 07/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP3000X | P95998 | NY | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 207L00000X | 01083540A | IN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 300038584 | 05 | IN | MEDICAID |