Healthcare Provider Details

I. General information

NPI: 1467363622
Provider Name (Legal Business Name): KREEM ELHAG IBRAHIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

813 N THOMPSON DR APT 203
MADISON WI
53704-7897
US

IV. Provider business mailing address

1859 118TH AVE NE
BLAINE MN
55449-7902
US

V. Phone/Fax

Practice location:
  • Phone: 763-328-7408
  • Fax:
Mailing address:
  • Phone: 763-328-7408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: