Provider Demographics
NPI:1154676096
Name:MEBRAHTOM TESFAI PLLC
Entity Type:Organization
Organization Name:MEBRAHTOM TESFAI PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:MEBRAHTOM
Authorized Official - Middle Name:WOLDU
Authorized Official - Last Name:TESFAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-394-6045
Mailing Address - Street 1:1911B STRATHMORE DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-2117
Mailing Address - Country:US
Mailing Address - Phone:336-394-6045
Mailing Address - Fax:
Practice Address - Street 1:212 PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3624
Practice Address - Country:US
Practice Address - Phone:336-394-6045
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV23729261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care