Healthcare Provider Details

I. General information

NPI: 1932562089
Provider Name (Legal Business Name): ISLAM ABDEL-RAHMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2016
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5165 MCCARTY LN
LAFAYETTE IN
47905-8764
US

IV. Provider business mailing address

1200 W WHITE RIVER BLVD
MUNCIE IN
47303-4988
US

V. Phone/Fax

Practice location:
  • Phone: 765-448-8000
  • Fax: 765-868-4698
Mailing address:
  • Phone: 764-747-4492
  • Fax: 317-222-2126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License NumberP95998
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number01083540A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: