Maryam Khalil Ibrahim, MD

Primary specialty

Student in an Organized Health Care Education/Training ProgramTaxonomy code 390200000X

Practice address

55 Fruit St
Boston, MA 02114

Phone

(617) 724-4133

NPI assigned

May 12, 2020

Reactivated

Feb 17, 2022

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in MA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1589241600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1645142400000",
    "number": "1154943157",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1 EMERSON PLACE",
            "address_2": "APT 4P",
            "city": "BOSTON",
            "state": "MA",
            "postal_code": "02114",
            "telephone_number": "617-697-5705"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "55 FRUIT ST",
            "city": "BOSTON",
            "state": "MA",
            "postal_code": "02114",
            "telephone_number": "617-724-4133"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "IBRAHIM",
        "first_name": "MARYAM",
        "middle_name": "KHALIL",
        "credential": "MD",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2020-05-12",
        "last_updated": "2022-02-18",
        "certification_date": "2022-02-18",
        "deactivation_date": "2022-01-11",
        "reactivation_date": "2022-02-17",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Amir E Ibrahim, MD
• Fadi Ibrahim, MD
• Ishaq O Ibrahim, MD
• Khaled Ibrahim
• Mary Ibrahim
• Nadeen Ibrahim
• Nasrien Ezzeldin Ibrahim, MD
• Osama Khalil Abdelaziz Ibrahim
• Rand Ibrahim, MD
• Ronnie Ibrahim, MD

• Student in an Organized Health Care Education/Training Program in Boston, MA
• Providers in Boston, MA by specialty
• Student in an Organized Health Care Education/Training Program in Massachusetts

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 18, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.