Healthcare Provider Details

I. General information

NPI: 1184067829
Provider Name (Legal Business Name): IBTESAM M RAFEEA M D P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2013
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5266 SCHAEFER RD
DEARBORN MI
48126-3228
US

IV. Provider business mailing address

5266 SCHAEFER RD
DEARBORN MI
48126-3228
US

V. Phone/Fax

Practice location:
  • Phone: 951-992-7156
  • Fax:
Mailing address:
  • Phone: 951-992-7156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301085086
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: IBTESAM M RAFEEA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 951-992-7156