1881819712 NPI number — TSION HAILESELASSIE, MD, PA, D.B.A GAINESVILLE PEDIATRICS

Table of content: (NPI 1881819712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881819712 NPI number — TSION HAILESELASSIE, MD, PA, D.B.A GAINESVILLE PEDIATRICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TSION HAILESELASSIE, MD, PA, D.B.A GAINESVILLE PEDIATRICS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1881819712
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
426 N GRAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76240-4324
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
940-665-9915
Provider Business Mailing Address Fax Number:
940-665-9962

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
426 N GRAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76240-4324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-665-9915
Provider Business Practice Location Address Fax Number:
940-665-9962
Provider Enumeration Date:
04/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HAILESELASSIE
Authorized Official First Name:
TSION
Authorized Official Middle Name:
ELAINE
Authorized Official Title or Position:
PHYSICIAN OWNER
Authorized Official Telephone Number:
940-665-9915

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  L5755 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 156051802 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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