1023052867 NPI number — FISEHATSION G MEHARI MD

Table of content: FISEHATSION G MEHARI MD (NPI 1023052867)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023052867 NPI number — FISEHATSION G MEHARI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEHARI
Provider First Name:
FISEHATSION
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023052867
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2315 HENSLOWE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POTOMAC
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20854-2951
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-802-9353
Provider Business Mailing Address Fax Number:
301-977-9958

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15225 SHADY GROVE RD STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20850-3252
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-977-9959
Provider Business Practice Location Address Fax Number:
301-977-9958
Provider Enumeration Date:
06/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  D0064478 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: J443-0016 . This is a "CAREFIRST BLUE SHIELD" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".




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