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General NPI Number Information
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NPI Number | 1639676596
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Entity Type | Organization
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Legal Business Name | S T IBRAHIM MEDICAL P.C
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Dates
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Enumeration Date | 04/09/2018
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Last Update Date | 04/09/2018
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Provider Practice Location Address
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Address Line | 112 KNICKERBOCKER RD
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City | DEMAREST
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State | NJ
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Zip | 07627-1026
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Country | US
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Telephone | 856-221-8225
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Fax | 201-331-3637
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Provider Business Mailing Address
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Address Line | 112 KNICKERBOCKER RD
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City | DEMAREST
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State | NJ
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Zip | 07627-1026
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Country | US
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Telephone | 856-221-8225
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Fax | 201-331-3637
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Authorized Official
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Title or Position | OWNER
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Name | DR. SYED TARIQ IBRAHIM
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Credential | MD
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Telephone | 856-221-8225
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State | NJ
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