1215129341 NPI number — IBRAHIM S ABU ROMEH M.D

Table of content: IBRAHIM S ABU ROMEH M.D (NPI 1215129341)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215129341 NPI number — IBRAHIM S ABU ROMEH M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ABU ROMEH
Provider First Name:
IBRAHIM
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215129341
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 N SHADELAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46219-4959
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1115 RONALD REAGAN PKWY
Provider Second Line Business Practice Location Address:
STE 171
Provider Business Practice Location Address City Name:
AVON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46123-6910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-217-3000
Provider Business Practice Location Address Fax Number:
317-273-5988
Provider Enumeration Date:
08/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  4301100113 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: 01077129A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X , with the licence number: 01077129A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1598968547 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: D0072852 . This is a "STATE LICENSE #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 11808031 . This is a "CAQH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1215129341 . This is a "BCBS TYPE 1 (IND) NPI #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5315053798 . This is a "CDS #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4301081138 . This is a "MI LICENSE #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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