Healthcare Provider Details

I. General information

NPI: 1962609222
Provider Name (Legal Business Name): IBRAHIM ISAMAIL GHANNAM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 06/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 N CENTRAL AVE STE 1600
PHOENIX AZ
85004-4633
US

IV. Provider business mailing address

242 W MAHOGANY PL
CHANDLER AZ
85248-6387
US

V. Phone/Fax

Practice location:
  • Phone: 602-262-8900
  • Fax:
Mailing address:
  • Phone: 480-861-3401
  • Fax: 480-861-3401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number005544
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2308
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: