Healthcare Provider Details

I. General information

NPI: 1699018333
Provider Name (Legal Business Name): SOFIA IBRAHIM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2013
Last Update Date: 09/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S 1ST AVE LOYOLA UNIVERSITY MEDICAL CENTER, FAHEY PSYCHIATRY
MAYWOOD IL
60153-3328
US

IV. Provider business mailing address

2160 S 1ST AVE LOYOLA UNIVERSITY MEDICAL CENTER, FAHEY PSYCHIATRY
MAYWOOD IL
60153-3328
US

V. Phone/Fax

Practice location:
  • Phone: 708-216-3750
  • Fax: 708-216-6840
Mailing address:
  • Phone: 708-216-3750
  • Fax: 708-216-6840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number125.062585
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: