1578750006 NPI number — TEWODROS FESSEHA, M.D., P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578750006 NPI number — TEWODROS FESSEHA, M.D., P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TEWODROS FESSEHA, M.D., P.C.
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:
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:
1578750006
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20905 GREENFIELD RD
Provider Second Line Business Mailing Address:
SUITE 407
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48075-5360
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-552-8525
Provider Business Mailing Address Fax Number:
248-552-1134

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20905 GREENFIELD RD
Provider Second Line Business Practice Location Address:
SUITE 407
Provider Business Practice Location Address City Name:
SOUTHFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48075-5360
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-552-8525
Provider Business Practice Location Address Fax Number:
248-552-1134
Provider Enumeration Date:
09/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FESSEHA
Authorized Official First Name:
TEWODROS
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-552-8525

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  4101056254 , 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)

  • Identifier: 3406311902 . This is a "BLUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4132714 10 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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