Healthcare Provider Details

I. General information

NPI: 1245480037
Provider Name (Legal Business Name): MOHAMED A IBRAHIM R.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2008
Last Update Date: 09/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3738 CHOUTEAU AVE STE 200
SAINT LOUIS MO
63110-2546
US

IV. Provider business mailing address

3738 CHOUTEAU AVE STE 200
SAINT LOUIS MO
63110-2546
US

V. Phone/Fax

Practice location:
  • Phone: 314-772-8801
  • Fax: 314-772-7988
Mailing address:
  • Phone: 314-772-8801
  • Fax: 314-772-7988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2008009830
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: