Basic Information
Provider Information | |||||||||
NPI: | 1073752036 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AYALEW | ||||||||
FirstName: | TARIKU | ||||||||
MiddleName: | DAMTE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 225 SOUTH WHITING STREET APT 605 | ||||||||
Address2: |   | ||||||||
City: | ALEXANDRIA | ||||||||
State: | VA | ||||||||
PostalCode: | 22304 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3016183772 | ||||||||
FaxNumber: | 3016182986 | ||||||||
Practice Location | |||||||||
Address1: | 16000 JOHNSTON MEMORIAL DRIVE | ||||||||
Address2: |   | ||||||||
City: | ABINGDON | ||||||||
State: | VA | ||||||||
PostalCode: | 24211 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3016183772 | ||||||||
FaxNumber: | 3016182986 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/16/2009 | ||||||||
LastUpdateDate: | 02/12/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 0101250064 | VA | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 208M00000X | MD18942 | ME | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 208M00000X | MD2011-0811 | NM | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207R00000X | 0101250064 | VA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | MD18942 | ME | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | MD2011-0811 | NM | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.