Provider Demographics
NPI:1164718466
Name:HAILEMARIAM, YARED BERHANU (MD)
Entity Type:Individual
Prefix:
First Name:YARED
Middle Name:BERHANU
Last Name:HAILEMARIAM
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 1:5200 COMMERCE CROSSINGS DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-2182
Mailing Address - Country:US
Mailing Address - Phone:502-253-4924
Mailing Address - Fax:502-489-5750
Practice Address - Street 1:3900 KRESGE WAY STE 60
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4690
Practice Address - Country:US
Practice Address - Phone:502-893-7710
Practice Address - Fax:502-893-1391
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-24
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY48993207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY48993OtherMEDICAL LICENSE