Provider Demographics
NPI:1023386901
Name:GEBREANANYA, ZELALEM ATAKILT (MD)
Entity Type:Individual
Prefix:
First Name:ZELALEM
Middle Name:ATAKILT
Last Name:GEBREANANYA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 MATTHEWS TOWNSHIP PKWY
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-4656
Practice Address - Country:US
Practice Address - Phone:704-384-9740
Practice Address - Fax:704-384-9565
Is Sole Proprietor?:No
Enumeration Date:2011-12-07
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-01514207R00000X
NCMATTHEWS208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1023386901Medicaid
SCNC2379Medicaid
NCNCB129EMedicare PIN
NCNCB129CMedicare PIN
NC1023386901Medicaid
NCNCB129DMedicare PIN