Healthcare Provider Details

I. General information

NPI: 1447346127
Provider Name (Legal Business Name): SYED T. IBRAHIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 S JACKSON ST
POTTSVILLE PA
17901-3625
US

IV. Provider business mailing address

2407 CAMBRIDGE CIR
HATFIELD PA
19440-1491
US

V. Phone/Fax

Practice location:
  • Phone: 570-621-5500
  • Fax: 570-621-5077
Mailing address:
  • Phone: 570-621-5500
  • Fax: 570-621-5077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number222749
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD444758
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code204R00000X
TaxonomyElectrodiagnostic Medicine Physician
License NumberMD444758
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: