Basic Information
Provider Information | |||||||||
NPI: | 1780927657 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GEBREMEDHIN | ||||||||
FirstName: | TESFAYE | ||||||||
MiddleName: | HABTETSION | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2124 S SANCTUARY DR | ||||||||
Address2: |   | ||||||||
City: | NEW BERLIN | ||||||||
State: | WI | ||||||||
PostalCode: | 531511923 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4146884534 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | W180N8085 TOWN HALL RD | ||||||||
Address2: |   | ||||||||
City: | MENOMONEE FALLS | ||||||||
State: | WI | ||||||||
PostalCode: | 530513518 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2622511000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/29/2013 | ||||||||
LastUpdateDate: | 06/21/2016 | ||||||||
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 | 207R00000X | 63225 - 20 | WI | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.