Healthcare Provider Details

I. General information

NPI: 1568196244
Provider Name (Legal Business Name): CARDIASPACE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2022
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 W BROADWAY STE 300
SALT LAKE CTY UT
84101-2044
US

IV. Provider business mailing address

50 W BROADWAY STE 300
SALT LAKE CTY UT
84101-2044
US

V. Phone/Fax

Practice location:
  • Phone: 801-738-8938
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MAJD IBRAHIM
Title or Position: CEO
Credential: MD
Phone: 248-890-2909