MEDICARE: JIBRAAN AHMED FAWAD

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	2080P0206X	Pediatric Gastroenterology Physician	MT229010	PA

General Provider Information

NPI Number	:	1528682739
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JIBRAAN AHMED FAWAD

Provider Business Mailing Address
First Line	:	3401 CIVIC CENTER BLVD
Second Line	:	DIVISION OF GASTROENTEROLOGY
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-4319
Country	:	US
Telephone Number	:	267-425-2739
Fax Number	:

Provider Business Practice Location Address
First Line	:	3401 CIVIC CENTER BLVD
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-4319
Country	:	US
Telephone Number	:	267-425-2739
Fax Number	:

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

Provider Enumeration Date	:	06/03/2020
Last Update Date	:	04/03/2026

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