Active NPI
Abbas M.B Ibrahim Sr.
- Surgical Physician Assistant
- Blue Island, IL
National Provider Identifier
1396017984
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Surgical Physician Assistant
- License
- 238.000314
- Practice address
- 12935 S Gregory Street
Blue Island, IL 60406 - Phone
- (708) 597-2000
- NPI assigned
- Jan 30, 2012
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Surgical Physician Assistant | 363AS0400X | 238.000314 | IL | Primary |
Addresses
Primary practice location
12935 S Gregory Street
Blue Island, IL 60406
Mailing address
10600 Brooks Lane
Chicago Ridge, IL 60415
Phone (708) 717-3841
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 238.000314 | IL | MD | Surgical Physician Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1327881600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1327881600000",
"number": "1396017984",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "10600 BROOKS LANE",
"city": "CHICAGO RIDGE",
"state": "IL",
"postal_code": "60415",
"telephone_number": "708-717-3841"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "12935 S GREGORY STREET",
"city": "BLUE ISLAND",
"state": "IL",
"postal_code": "60406",
"telephone_number": "708-597-2000"
}
],
"practiceLocations": [],
"basic": {
"last_name": "IBRAHIM",
"first_name": "ABBAS",
"middle_name": "M.B",
"name_suffix": "Sr.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2012-01-30",
"last_updated": "2012-01-30",
"status": "A"
},
"taxonomies": [
{
"code": "363AS0400X",
"taxonomy_group": "",
"desc": "Physician Assistant, Surgical",
"state": "IL",
"license": "238.000314",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Blue Island, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 30, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.