Basic Information
| Provider Information | |||||||||
| NPI: | 1245527845 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SALLOUM | ||||||||
| FirstName: | IBRAHEM | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 825 CHALKSTONE AVE | ||||||||
| Address2: | GRADUATE MEDICAL EDUCATION | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029084728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4015884001 | ||||||||
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| Practice Location | |||||||||
| Address1: | 164 SUMMIT AVE | ||||||||
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| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029062853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017934489 | ||||||||
| FaxNumber: | 4017934047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2011 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | LP02361 | RI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD14622 | RI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.