Healthcare Provider Details

I. General information

NPI: 1356523385
Provider Name (Legal Business Name): JIBRIALLAH BERMUDAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2007
Last Update Date: 11/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1197 BEAVER RUIN RD STE 102
NORCROSS GA
30093-6802
US

IV. Provider business mailing address

1112 IVEY PARK LN
NORCROSS GA
30092-4786
US

V. Phone/Fax

Practice location:
  • Phone: 770-912-2491
  • Fax:
Mailing address:
  • Phone: 770-912-2491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175M00000X
TaxonomyLay Midwife
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: