Provider Demographics
NPI:1760218812
Name:KOUROUMA, IBRAHIM
Entity type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:
Last Name:KOUROUMA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 BRAEBURN CIR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-2603
Mailing Address - Country:US
Mailing Address - Phone:734-819-3101
Mailing Address - Fax:734-527-6017
Practice Address - Street 1:2605 BRAEBURN CIR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-2603
Practice Address - Country:US
Practice Address - Phone:734-819-3101
Practice Address - Fax:734-527-6017
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-13
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI9860393251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health