Basic Information
| Provider Information | |||||||||
| NPI: | 1952588527 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIHRETU | ||||||||
| FirstName: | TAFFERE | ||||||||
| MiddleName: | NEGAT | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 658 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305030658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707181122 | ||||||||
| FaxNumber: | 7705357445 | ||||||||
| Practice Location | |||||||||
| Address1: | 743 SPRING ST NE | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705336645 | ||||||||
| FaxNumber: | 7705352642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2008 | ||||||||
| LastUpdateDate: | 01/21/2009 | ||||||||
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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 | 061295 | GA | Y | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 61295 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01228735 | 01 | GA | AMERIGROUP | OTHER | 9940207 | 01 | GA | AETNA | OTHER | 257247600A | 05 | GA | MEDICAID | 110029C049457 | 01 | GA | TRAILBLAZER | OTHER | 2091719 | 01 | GA | CIGNA | OTHER | 459354 | 01 | GA | WELLCARE | OTHER | 52233997 | 01 | GA | BCBS | OTHER |