Basic Information
| Provider Information | |||||||||
| NPI: | 1518031889 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIFETEW | ||||||||
| FirstName: | HANNA | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636930 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139815213 | ||||||||
| FaxNumber: | 5139815015 | ||||||||
| Practice Location | |||||||||
| Address1: | 730 W MARKET ST | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458014602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192664310 | ||||||||
| FaxNumber: | 4192264315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 11/26/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35088628 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2713504 | 05 | OH | MEDICAID |