MEDICARE: CARDIASPACE PLLC

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	207RC0000X	Cardiovascular Disease Physician

General Provider Information

NPI Number	:	1568196244
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARDIASPACE PLLC

Provider Business Mailing Address
First Line	:	50 W BROADWAY STE 300
Second Line	:
City	:	SALT LAKE CTY
State	:	UT
Zip	:	84101-2044
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	50 W BROADWAY STE 300
Second Line	:
City	:	SALT LAKE CTY
State	:	UT
Zip	:	84101-2044
Country	:	US
Telephone Number	:	801-738-8938
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. MAJD IBRAHIM
Credential	:	MD
Telephone Number	:	248-890-2909

Provider Enumeration Date	:	07/11/2022
Last Update Date	:	10/26/2022

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