=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225365869
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IBRAHIM KOURY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2009
-----------------------------------------------------
Last Update Date | 04/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 E ROLLINS ST
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32803-1248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-200-2355
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2600 WESTHALL LN FL 4
-----------------------------------------------------
City | MAITLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32751-7102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-200-2355
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 57016748
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | ME124347
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------