Basic Information
| Provider Information | |||||||||
| NPI: | 1043547938 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAKONNEN G HABTEMARIAM PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11773 | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852480013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809077707 | ||||||||
| FaxNumber: | 4809077097 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 E VAN BUREN ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850063742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809077707 | ||||||||
| FaxNumber: | 4809077097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2009 | ||||||||
| LastUpdateDate: | 04/24/2015 | ||||||||
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| AuthorizedOfficialLastName: | HABTEMARIAM | ||||||||
| AuthorizedOfficialFirstName: | MAKONNEN | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 4809077707 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 331918 | 05 | AZ | MEDICAID |