Provider Demographics
NPI:1447346127
Name:IBRAHIM, SYED T (MD)
Entity type:Individual
Prefix:DR
First Name:SYED
Middle Name:T
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2407 CAMBRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:HATFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:19440-1491
Mailing Address - Country:US
Mailing Address - Phone:570-621-5500
Mailing Address - Fax:570-621-5077
Practice Address - Street 1:420 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3625
Practice Address - Country:US
Practice Address - Phone:570-621-5500
Practice Address - Fax:570-621-5077
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2227492084P0800X
PAMD4447582084P0800X, 204R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02499585Medicaid
323BR1Medicare PIN
NY02499585Medicaid