Provider Demographics
NPI:1063428217
Name:CENTRAL INDIANA PHYSICAL MEDICINE & REHAB
Entity type:Organization
Organization Name:CENTRAL INDIANA PHYSICAL MEDICINE & REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-213-3024
Mailing Address - Street 1:2001 N GRANVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-2110
Mailing Address - Country:US
Mailing Address - Phone:765-213-3238
Mailing Address - Fax:765-284-2434
Practice Address - Street 1:1107 S TILLOTSON AVE
Practice Address - Street 2:STE 1
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-4517
Practice Address - Country:US
Practice Address - Phone:765-213-3024
Practice Address - Fax:765-282-9303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
194890Medicare ID - Type Unspecified