1194619197 NPI number — WEGAHTA KIDANE GHEBREIYESUS MD

Table of content: WEGAHTA KIDANE GHEBREIYESUS MD (NPI 1194619197)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194619197 NPI number — WEGAHTA KIDANE GHEBREIYESUS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GHEBREIYESUS
Provider First Name:
WEGAHTA
Provider Middle Name:
KIDANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1194619197
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/04/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 JEFFERSON AVE
Provider Second Line Business Mailing Address:
SUITE 305
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-685-4615
Provider Business Mailing Address Fax Number:
616-685-3033

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 LAFAYETTE AVE
Provider Second Line Business Practice Location Address:
SUITE 3000
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-685-6919
Provider Business Practice Location Address Fax Number:
616-685-3063
Provider Enumeration Date:
06/04/2025

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:  4351054941 , 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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