Healthcare Provider Details

I. General information

NPI: 1841243649
Provider Name (Legal Business Name): TAHCIN IBRAHIM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 02/01/2023
Certification Date: 02/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MARYS AVE
KINGSTON NY
12401-5829
US

IV. Provider business mailing address

19 BRADHURST AVE STE 3100N
HAWTHORNE NY
10532-2140
US

V. Phone/Fax

Practice location:
  • Phone: 845-338-2500
  • Fax: 845-331-2530
Mailing address:
  • Phone: 914-909-9018
  • Fax: 914-909-9028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number296592
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036063818
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number036063818
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA40663
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: