Healthcare Provider Details

I. General information

NPI: 1780030833
Provider Name (Legal Business Name): NEIL IBRAHIM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2016
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 KOOTENAI HEALTH WAY
COEUR D ALENE ID
83814-6051
US

IV. Provider business mailing address

355 GRAND ST INTERNAL MEDICINE DEPARTMENT
JERSEY CITY NJ
07302-4321
US

V. Phone/Fax

Practice location:
  • Phone: 208-625-6900
  • Fax: 208-625-6910
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2024039467
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberM-16637
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: