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NPI Code Detail

MEDICARE: BRIDGET BASILE IBRAHIM

MEDICARE: BRIDGET BASILE IBRAHIM
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
1363LF0000XFamily Nurse PractitionerRN270470MA

General Provider Information

NPI Number : 1437587219
Entity Type Code : Individual
Provider Name (Legal Business Name) : BRIDGET BASILE IBRAHIM
Provider Business Mailing Address
First Line : 1575 BLUE HILL AVE
Second Line : MATTAPAN COMMUNITY HEALTH CENTER
City : BOSTON
State : MA
Zip : 02126-2122
Country : US
Telephone Number : 617-296-0061
Fax Number : 617-296-5408
Provider Business Practice Location Address
First Line : 1575 BLUE HILL AVE
Second Line : MATTAPAN COMMUNITY HEALTH CENTER
City : BOSTON
State : MA
Zip : 02126-2122
Country : US
Telephone Number : 617-296-0061
Fax Number : 617-296-5408
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/14/2013
Last Update Date : 10/14/2013

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Directions to “ BRIDGET BASILE IBRAHIM ” Practice Location

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