Basic Information
| Provider Information | |||||||||
| NPI: | 1093760290 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEMMA | ||||||||
| FirstName: | GIRUM | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2550 UNIVERSITY AVE W STE 110N | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551142001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516025311 | ||||||||
| FaxNumber: | 6512226786 | ||||||||
| Practice Location | |||||||||
| Address1: | 6025 LAKE RD STE 110 | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551251709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517357414 | ||||||||
| FaxNumber: | 6517351827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 02/21/2018 | ||||||||
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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 | 208M00000X | 01062226A | IN | N | Allopathic & Osteopathic Physicians | Hospitalist | 207RH0003X | 52821 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 9450969 | 01 | IN | PHCS PID NUMBER | OTHER | 000000485519 | 01 | IN | ANTHEM PROVIDER NUMBER | OTHER | 200827030 | 05 | IN | MEDICAID |