Healthcare Provider Details

I. General information

NPI: 1093747818
Provider Name (Legal Business Name): ROSE M. IBRAHIM M.D. PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 01/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13739 S HURON RIVER DR
ROMULUS MI
48174-3628
US

IV. Provider business mailing address

1598 OLD CHATHAM DR
BLOOMFIELD HILLS MI
48304-1040
US

V. Phone/Fax

Practice location:
  • Phone: 734-941-0895
  • Fax:
Mailing address:
  • Phone: 734-941-0895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4301046478
License Number StateMI

VIII. Authorized Official

Name: ROSE IBRAHIM
Title or Position: PRESIDENT
Credential:
Phone: 734-941-0895