1215195748 NPI number — INDRYAS LEMMA WOLDIE MD

Table of content: INDRYAS LEMMA WOLDIE MD (NPI 1215195748)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215195748 NPI number — INDRYAS LEMMA WOLDIE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOLDIE
Provider First Name:
INDRYAS
Provider Middle Name:
LEMMA
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:
1215195748
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/25/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1420 STEPHENSON HWY
Provider Second Line Business Mailing Address:
SUITE 400-CREDENTIALING
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48083-1189
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-581-5977
Provider Business Mailing Address Fax Number:
248-581-5640

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4201 ST. ANTOINE
Provider Second Line Business Practice Location Address:
SUITE 7B
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48201-2153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-745-2554
Provider Business Practice Location Address Fax Number:
313-993-0295
Provider Enumeration Date:
05/31/2008

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:  4301088450 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X , with the licence number: 4301088450 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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