Provider Demographics
NPI:1992764674
Name:MOUSHIRA A EBRAHIM
Entity type:Organization
Organization Name:MOUSHIRA A EBRAHIM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MOUSHIRA
Authorized Official - Middle Name:ANWAR
Authorized Official - Last Name:EBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-454-4051
Mailing Address - Street 1:PO BOX 1888
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75403-1888
Mailing Address - Country:US
Mailing Address - Phone:903-455-4051
Mailing Address - Fax:903-454-1716
Practice Address - Street 1:4818 WELLINGTON ST
Practice Address - Street 2:SUITE 4
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75402-6010
Practice Address - Country:US
Practice Address - Phone:903-455-4051
Practice Address - Fax:903-455-4051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX094948902Medicaid
TX094948902Medicaid