Healthcare Provider Details

I. General information

NPI: 1487534889
Provider Name (Legal Business Name): AMJAD IBRAHIM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2025
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 S MAIN ST
ROYAL OAK MI
48067-2676
US

IV. Provider business mailing address

2969 ORCHARD PL
ORCHARD LAKE MI
48324-2362
US

V. Phone/Fax

Practice location:
  • Phone: 248-216-4704
  • Fax: 947-245-4212
Mailing address:
  • Phone: 248-755-8585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704311666
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: