1225034135 NPI number — MAHTEME SELASSIE MD

Table of content: MAHTEME SELASSIE MD (NPI 1225034135)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225034135 NPI number — MAHTEME SELASSIE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SELASSIE
Provider First Name:
MAHTEME
Provider Middle Name:
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:
1225034135
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/16/2006
NPI Reactivation Date:
03/21/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7910 WOODMONT AVE
Provider Second Line Business Mailing Address:
STE 460
Provider Business Mailing Address City Name:
BETHESDA
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20814-3066
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-934-8811
Provider Business Mailing Address Fax Number:
301-934-9321

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7910 WOODMONT AVE
Provider Second Line Business Practice Location Address:
STE 460
Provider Business Practice Location Address City Name:
BETHESDA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20814-3066
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-934-8811
Provider Business Practice Location Address Fax Number:
301-934-9321
Provider Enumeration Date:
06/24/2005

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: 2084P0800X , with the licence number:  04944 , 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: 567898 . This is a "NCPPO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 141971 . This is a "VALUE OPTIONS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: M5790001 . This is a "BLUE CROSS" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 2129679 . This is a "MAMSI/ALLIANCE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 583BMA . This is a "BLUE CROSS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com