Basic Information
| Provider Information | |||||||||
| NPI: | 1639150121 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAILE | ||||||||
| FirstName: | ZEWDU | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 135 N OAK ST | ||||||||
| Address2: | |||||||||
| City: | HINSDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605213860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308568900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 135 N OAK ST | ||||||||
| Address2: | |||||||||
| City: | HINSDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605213860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308568900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 10/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036-091812 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 036091812 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 821050 | 01 | IL | MEDICARE GROUP PTAN | OTHER |