Healthcare Provider Details

I. General information

NPI: 1891365698
Provider Name (Legal Business Name): GENA IBRAHIM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2021
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LAFAYETTE AVE SE STE 4000
GRAND RAPIDS MI
49503-4692
US

IV. Provider business mailing address

300 LAFAYETTE AVE SE STE 4000
GRAND RAPIDS MI
49503-4692
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-6922
  • Fax:
Mailing address:
  • Phone: 616-685-6922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4351048380
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: