=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679672216
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUCY IBRAHIM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 N OAK ST
-----------------------------------------------------
City | HINSDALE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60521-3829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-856-9000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 777 OAKMONT LN SUITE 1600
-----------------------------------------------------
City | WESTMONT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60559-5511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-789-2550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE PROPRIETOR
-----------------------------------------------------
Name | LUCY IBRAHIM
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 630-789-2550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084A0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Psychiatry & Neurology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------