MEDICARE: DENISE THERESA IBRAHIM D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207XP3100X	Pediatric Orthopaedic Surgery Physician	036105854	IL
2	207X00000X	Orthopaedic Surgery Physician	036105854	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00610091	OTHER	IL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164418869
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENISE THERESA IBRAHIM D.O.

Provider Business Mailing Address
First Line	:	1860 PAYSPHERE CIR
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60674-3698
Country	:	US
Telephone Number	:	630-469-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	133 E BRUSH HILL RD
Second Line	:
City	:	ELMHURST
State	:	IL
Zip	:	60126-5659
Country	:	US
Telephone Number	:	630-501-0630
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2005
Last Update Date	:	10/07/2021

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