Basic Information
| Provider Information | |||||||||
| NPI: | 1740256445 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BSHARA | ||||||||
| FirstName: | IBRAHIM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20525 CENTER RIDGE RD | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | ROCKY RIVER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408955056 | ||||||||
| FaxNumber: | 4403332935 | ||||||||
| Practice Location | |||||||||
| Address1: | 3665 W 117TH ST | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441115215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2163510778 | ||||||||
| FaxNumber: | 2162515963 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 09/29/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35063037B | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000031825 | 01 | OH | ANTHEM | OTHER | 10789186 | 01 | CAQH | OTHER | 1780634279 | 01 | GROUP NPI | OTHER | 0119204 | 01 | GROUP MEDICAID | OTHER | 3610861 | 01 | GROUP ASC MEDICARE | OTHER | 109285 | 01 | KAISER | OTHER | CA4511 | 01 | GROUP RR MEDICARE | OTHER | CA4511 | 01 | RR MEDICARE GROUP | OTHER | 0874362 | 05 | OH | MEDICAID | 110099557 | 01 | RR MEDICARE INDIVIDUAL | OTHER | 9273172 | 01 | GROUP MEDICARE | OTHER | D368301 | 01 | GROUP IND DIAGNOSTICS MED | OTHER |