1801855697 NPI number — MAHTEME SELASSIE, MDPA

Table of content: (NPI 1801855697)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801855697 NPI number — MAHTEME SELASSIE, MDPA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAHTEME SELASSIE, MDPA
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:
1801855697
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/29/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7910 WOODMONT AVE
Provider Second Line Business Mailing Address:
SUITE 460
Provider Business Mailing Address City Name:
BETHESDA
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20814-3002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-656-9520
Provider Business Mailing Address Fax Number:
301-718-3633

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7910 WOODMONT AVE
Provider Second Line Business Practice Location Address:
SUITE 460
Provider Business Practice Location Address City Name:
BETHESDA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20814-3002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-656-9520
Provider Business Practice Location Address Fax Number:
301-718-3633
Provider Enumeration Date:
03/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SELASSIE
Authorized Official First Name:
MAHTEME
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
301-656-9520

Provider Taxonomy Codes

  • Taxonomy code: 2084P0804X , with the licence number:  D0052686 , 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: M44625 . This is a "CDS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: D0052686 . This is a "STATE LICENSE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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