MEDICARE: DR. KHALID SHAKER IBRAHIM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	57.012754	OH

General Provider Information

NPI Number	:	1336315001
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KHALID SHAKER IBRAHIM MD

Provider Business Mailing Address
First Line	:	12000 FAIRHILL ROAD, APT 202
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44120
Country	:	US
Telephone Number	:	216-650-8751
Fax Number	:

Provider Business Practice Location Address
First Line	:	12000 FAIRHILL RD APT 202
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44120-1052
Country	:	US
Telephone Number	:	216-650-8751
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2008
Last Update Date	:	05/02/2008

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